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Full text of "Modern surgery, general and operative"

Columbia iHnftJersfitp 
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MODERN SURGERY 

GENERAL AND OPERATIVE 



JOHN CHALMERS DA COSTA, M.D. 

PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY, JEFFERSON 

MEDICAL COLLEGE, PHILADELPHIA; SURGEON TO THE PHILADELPHIA HOSPITAL 

AND CONSULTING SURGEON TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA 



Fifth Edition, Thoroughly Revised and Enlarged 

with 

872 Illustrations, some of them in Colors 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1907 












Set up, electrotyped, printed, and copyrighted October, 1S94. Reprinted March, 1895, and August, 1896. 
Revised, entirely reset, reprinted, and recopyrighted June, 189S. Reprinted October, 1898, 
and June, 1S99. Revised, reprinted, and recopyrighted August, 1900. Reprinted 
August, 1901 ; August, 1902, and November, 1902. Revised, entirely 
reset, reprinted, and recopyrighted, August, 1903. 
Reprinted July, 1904; October, 1905; September, 
1906, and October, 1906. Revised, re- 
printed, and recopyrighted 
January, 1907. 



Copyright, 1907, by W. B. Saunders Company 



*S COM PAN Y, 



THIS VOLUME IS 
DEDICATED, WITH AFFECTIONATE REGARD, TO 

DR. ORVILLE HORWITZ, 

THE FELLOW-STUDENT, THE HOSPITAL ASSOCIATE, AND 
THE TRUSTED FRIEND OF 

THE AUTHOR. 



PREFACE TO THE FIFTH EDITION 



In making this revision the book has been carefully gone over; many 
sections have been altered or expanded, and considerable new matter has been 
added. 

Among the sections altered, corrected, or expanded may be mentioned 
those upon hernia, ulcer of the stomach, cancer of the stomach, ulcer of the 
duodenum, tetanus, snake bites, syphilis of bones and joints, gonorrhea in 
children, concussion of the brain, compression of the brain, hydrocephalus, 
cephalocele, spina bifida, suture of the divided spinal cord, injuries by elec- 
tricity, fractures of the bones of the foot, surgical tuberculosis, cleft palate, 
Bier's method of congestive hyperemia, and perforation of the bowel in 
typhoid fever. 

The new matter added includes: Fracture of the carpal scaphoid, 
dislocation of the semilunar bone, operation for ununited fracture of the 
femoral neck, operations of Hugier and of Murphy for ankylosis, the treatment 
of whitlow by the plan of G. B. Mower White, operation for brachial birth 
palsy, operation for intracranial hemorrhage of the newborn as advocated 
by Cushing of Baltimore, treatment of neuralgia by injection of osmic acid, 
Ransohoff's plan of discission of the pleura in chronic empyema, Brophy's 
operation for cleft palate, artificial stimulation of phagocytosis, scopolamin- 
morphin anesthesia, local anesthesia by injection of stovain, operation for 
movable kidney, Monks method of identifying different portions of the small 
intestine, radium, Willy Meyer's operation for carcinoma of the mammary 
gland, Young's method of perineal prostatectomy, the interilio-abdominal 
amputation, Von Mosetig's method of filling bone cavities, the Johns Hopkins 
operation for inguinal hernia, the Quenu-Mayo operation for rectal cancer, 
Moynihan's short loop method of gastrojejunostomy, the no-loop method of 
gastrojejunostomy devised by the Mayo brothers, appendicostomy, the 
transverse incision for exposure of the vermiform appendix, malignant disease 
of the appendix, typhoid cholecystitis, Matas's operation for aneurysm, and 
the treatment of peritonitis by incision, drainage, the semi-erect position, 
and continuous low pressure proctolysis. A number of new cuts have also 
been added. 

2245 Walnut Street, Philadelphia 
February, 1907. 



PREFACE TO THE FIRST EDITION 



The aim of this Manual is to present in clear terms and in concise form 
the fundamental principles, the chief operations, and the accepted methods 
of modern surgery. The work seeks to stand between the complete but 
cumbrous text-book and the incomplete but concentrated compend. 

Obsolete and unessential methods have been excluded in favor of the 
living and the essential. There has been no attempt to exploit fanciful theories 
nor to defend unprovable hypotheses, but rather the effort has been to present 
the subject in a form useful alike to the student and to the busy practitioner. 

The opening chapter is devoted to Bacteriology because the author pro- 
foundly believes that without some knowledge of the vital principles of this 
branch of science the vast importance of its truths will be ill-appreciated, and 
there will be inevitable failure in the application of aseptic and antiseptic 
methods. 

Ophthalmology, gynecology, rhinology, otology, and laryngology have 
not been considered, because of the obvious fact that in the advanced state of 
specialized science only the specialist is competent to write upon each of these 
branches. 

In Orthopedic Surgery are discussed those conditions which must in the 
very nature of things often be cared for by the surgeon or the general prac- 
titioner (such as hip-joint disease, club-foot, Pott's disease of the spine, flat- 
foot, etc.). The limited space at command precluded the introduction of a 
special division on diseases of the female breast. A large amount of space 
has been devoted to Fractures and Dislocations, the enormous practical im- 
portance of these subjects calling for their full discussion. Operative Sur- 
gery is considered in separate sections, the most important procedures being 
fully described, giving also the instruments necessary, and the positions as- 
sumed by patient and operator. This method has been adopted to fit the 
work for use in surgical laboratories. 

Many systems, manuals, monographs, lectures, and journal articles have 
been consulted, and credit has been given in the text for statements and quota- 
tions. Special acknowledgment is due to the American Text-Book oj Surgcrv, 
edited by Keen and White; to the surgical works of Ashhurst, Agnew, the 
elder Gross, Duplay and Reclus, Esmarch, Albert, Koenig, Wyeth, and 
Bryant; to the Manna/ oj Surgery, edited by Treves; to the Internationa/ 
Encyclopedia oj Surgery, edited by Ashhurst; to. the Surgical Pathology of 
Billroth and of Bowlby; to the Diagnosis of A. Pearce Gould; to the Surgical 
Dictionary of Heath; to the Rest ami Pain of Hilton; to the works on opera- 
tive surgery of Barker, Jacobson, Treves, Stephen Smith, and Joseph Bell 
to the Minor Surgery of Wharton; to the dictionary of Foster and of Gould 
to the Principles oj Surgery of Senn; to the orthopedic writings of Savre 



12 Preface to the First Edition 

to the work on Diseases of the Male Generative Organs of Jacobson; to the 
System of Genito-urinary Diseases, edited by Morrow; and to the treatises on 
Fractures and Dislocations of Sir Astley Cooper, Malgaigne, Hamilton, Stim- 
son, and T. Pickering Pick. 

The Author returns his thanks to the numerous writers who courteously 
authorized the reproduction of special illustrations, and particularly to Pro- 
fessors Keen and White for their free permission to draw upon the American 
Text-Book o) Surgery, from which a number of pictures have been taken, 
distinctively those referring to Bandaging; to Mr. John Vansant for the 
great amount of labor so ably and cheerfully performed; and to Dr. Howard 
Dehoney for the preparation of the Index. 



CONTENTS 



PAGE 

I. Bacteriology 17 

II. Asepsis and Antisepsis 50 

III. Inflammation 73 

IV. Repair no 

V. Surgical Fevers 123 

VI. Suppuration and Abscess 127 

VII. Ulceration and Fistula 157 

VIII. Mortification or Gangrene 168 

IX. Thrombosis and Embolism 185 

X. Septicemia and Pyemia 195 

XI. Erysipelas (St. Anthony's Fire) 200 

XII. Ten anus or Lockjaw 204 

XIII. Tuberculosis 213 

XIV. Rickets 233 

XV. Contusions and Wounds 237 

XVI. Syphilis 274 

XVII. Tumors, or Morbid Growths 296 

XVIII. Diseases and Injuries of the Heart and Vessels 344 

Hemorrhage or Loss of Blood 375 

Operations on the Vascular System 395 

Ligation of Arteries in Continuity 401 

XIX. Diseases and Injuries of Bones and Joints 431 

Diseases of the Bones 431 

Fractures 446 

Diseases of the Joints 546 

Luxations or Dislocations 579 

Operations upon Bones and Joints 610 

XX. Diseases and Injuries of Muscles and Tendons 637 

Operations upon Muscles and Tendons 654 

XXL Orthopedic Surgery 658 

XXII. Diseases and Injuries of Nerves 666 

Diseases of Nerves 666 

Wounds and Injuries of Nerves 667 

Operations upon Nerves 676 

XXIII. Diseases and Injuries of the Head 686 

Diseases of the Head 6S6 

Injuries of the Head 696 

XXIV. Surgery of the Spine 740 

XXV. Surgery of the Respiratory Organs 765 

Diseases and Injuries of the Nose and Antrum 765 

Diseases and Injuries of the Larynx and Trachea 766 

Operations on the Larynx and Trachea 769 

Diseases and Injuries of the Chest, Pleura, and Lungs 771 

Operations on Pleura and Lungs 782 

!3 



14 Contents 



PAGE 

XXVI. Diseases and Injuries of the Upper Digestive Tract 788 

XXVII. Diseases and Injuries of the Abdomen 810 

Stomach and Intestines 822 

The Peritoneum 865 

The Liver, Gall-bladder, and Bile-Ducts 875 

The Pancreas 896 

The Spleen 902 

Operations upon the Abdomen 905 

XXVIII. Diseases and Injuries of the Rectum and Anus 1004 

XXIX. Anesthesia and Anesthetics 1029 

XXX. Burns and Scalds 1052 

XXXI. Diseases of the Skin and Nails 1056 

XXXII. Diseases and Injuries of the Thyroid Gland 1061 

XXXIII. Diseases and Injuries of the Lymphatics 1074 

XXXIV. Bandages 1080 

XXXV. Plastic Surgery 1089 

XXXVI. Diseases and Injuries of the Genito-urinary Organs 1094 

Diseases and Injuries of the Kidney and Ureter 1100 

Diseases and Injuries of the Bladder 11 25 

Diseases and Injuries of the Urethra, Penis, Testicles, Prostate, 

Seminal Vesicles, Spermatic Cord, and Tunica Vaginalis 1 149 

XXXVII. Amputations 1204 

Special Amputations 1209 

XXXVIII. Diseases of the Mammary Gland 1227 

XXXIX. Skiagraphy, or the Employment of the Rontgen Rays; The 

Finsen Light; Becquerel's Rays; Radium Rays 1244 

XL. Injuries by Electricity 1255 



INDEX 1259 



MODERN SURGERY 



MODERN SURGERY. 



I. BACTERIOLOGY. 

Bacteriology is the science of micro-organisms. Though a science in 
the youth of its years, bacteriology has not only profoundly altered, but it 
has also revolutionized, pathology, and our views of surgery would be in- 
complete, misleading, and erroneous without its aid. 

Micro=organisms, or microbes, are minute non-nucleated vegetable 
cells closely connected with fungi and algae, many of them being visible only 
by means of a highly powerful microscope and after they have been brightly 
stained. The contents of these cells are protoplasm and nuclear chromatin 
enclosed by a structure containing cellulose. There is considerable evidence 
that some diseases are caused by bacteria so minute as to escape detection even 
by the most powerful microscope. The French Yellow Fever Commission 
asserted that the yellow fever micro-organism passes through a porcelain filter 
("Annals of the Pasteur Institute," Nov., 1903). The micro-organism of 
rabies probably does the same thing. 

Even in the most remote times some have believed that "the mysterious 
cause of contagious and epidemic diseases must be sought in living entities" 
(Monti on "Modern Pathology ") . Bacteria were discovered by Leeuwenhoek 
in 1675, but definite knowledge of these minute bodies and of their actions 
dates from the study of fermentation by the celebrated Frenchman Pasteur, 
who in 1858 asserted that every fermentation has invariably its specific 
ferment; that this ferment consists of living cells; that these cells produce 
fermentation by absorbing the oxygen of the substance acted upon; that 
putrefaction is caused by an organized ferment; that all organized ferments 
are carried about in the air; and that entirely to exclude air prevents putre- 
faction or fermentation. 

In i860 Pasteur published the observation that sterile liquids will not 
be contaminated by air if the air gains entry only through a long curved 
tube, the reason being that dust and growths fall from the entering air by 
gravity ("Comptes rendus," i860). 

In 1863 Pasteur published his experiments which proved that beer cannot 
ferment without yeast and that wine received in sterile vessels and kept 
from external contamination will not undergo ammoniacal change. 

The views of Pasteur, which were radical departures from accepted belief, 
inaugurated a bitter controversy, and in that controversy were born the 
microbic theory of disease, the doctrine of preventive inoculation, antiseptic 
surgery, and serum-therapy. 

The word microbe, which signifies a small living being, was introduced 
in 1878 by the late Professor Sedillot, of Paris. At that time the nature of 
these bodies was in doubt; some thought them animal, and called them 
2 17 



i8 Bacteriology 

microzoaria ; others thought them vegetable, and called them microphyta; the 
designation "microbe" does not commit us to either view. We now know 
them to be vegetable, but the term "microbe" has remained in use. 

The micro-organisms connected with disease in man are divided into: 

i. Yeasts, Saccharomyces, or Blastomycetes; 

2. Moulds, or Hvphomycetes; 

3. Bacteria, or Schizomycetes. 

Yeasts or budding fungi include most of those fungi which can cause 
alcoholic fermentation in saccharine matter. They consist of small cells 
which can live without free oxygen, and which multiply by gemmation or 
budding. When a cell multiplies a small bud of protoplasm projects from 
or near the end of the cell. This bud increases progressively in size and a 
constriction appears between the bud and the parent-cell. The constriction 
deepens as the projection enlarges, until the bud attains the size of the parent. 
Thus a chain or series of rounded yeast-cells is formed. These cells contain 
spores when nourishment is insufficient. Under certain conditions yeast 
fungi can form interwoven threads called mycelial threads. 

Moulds or filamentous fungi consist of filaments, each filament being 
composed of a single row of cells arranged end to end, and all filaments 
springing from a germinal tube which grows from a germinating spore. The 
yeast fungi are the common but not the only cause of fermentation. Mould 
fungi are connected with processes of decomposition. Putrefaction is due 
to bacteria and retards the growth of yeast and moulds. 

Most yeasts and moulds grow best upon dead organic matter, some attack 
plants, a few the lower animals, and a very few grow upon or in the tissues 
of the human body. 

The oidium albicans is an yeast fungus which by growing in the mucous 
membrane produces the disease known as thrush. This disease attacks 
especially the mucous membrane of the mouth and pharynx, but occasionally 
the growth takes place upon the esophagus, the vocal cords, the stomach, 
the vagina, the respiratory tract, and the areola of the breast of a nursing 
woman. The proliferating fungus presents the appearance of milky white 
spots which by thickening and coalescence form curd-like masses, the super- 
ficial layer of epithelium being raised and cast off. 

Blastomycetes dermatitis is an inflammation of the skin due to yeast fungi 
and bearing a resemblance to tuberculosis or syphilis. Sanfelice and others 
maintain that yeasts are responsible for the growth of malignant tumors. It 

is certain that yeasts may exist in a carcinoma 
and can be cultivated, but proof is entirely 
lacking that they are anything but a con- 
tamination. Many skin diseases are due to 
fungi; among them should be mentioned: 
Favus, pityriasis versicolor, herpes tonsurans, 
parasitic sycosis, and eczema marginatum. 
Actinomycosis is due to the rav-fungus 

Fig. 1. — Actinomyces (Ziegler). . ..',.. 

(see page 272). It is uncertain in which 
group the ray-fungi should be placed; it is quite certain that more than one 
variety exists, and they seem to occupy a place between moulds and bacteria. 
Madura-joot, or mycetoma, is due to the streptothrix Madura'. 




Schizomycetes or Bacteria 19 

Schizomycetes or bacteria chiefly claim our attention. It is important 
to remember that the term " bacteria," though applied to the class schizomycetes. 
has also a more restricted application — that is, to a division of the class; it 
may mean either schizomycetes in general, or rod-shaped schizomycetes, whose 
length is not more than twice their breadth. In this work it is employed to 
designate schizomycetes as a class. 

Bacteria are minute, unbranched, non-nucleated, vegetable cells, free 
from chlorophyl, varying in shape and occasionally presenting locomotive 
flagella. The cell consists of a cell membrane, a layer of protoplasm, and some 
central fluid. Xo true nucleus has yet been demonstrated, but granules 
are found within the cells which some call metachromatic bodies (Babes) 
and others nuclei (Ernst). The cell membrane varies greatly in thickness, 
and when it is vary thick the cell is said to have a capsule. The round cells 
have a smooth outer surface, but some of the rod-shaped cells show many 
flagella or at the end a single flagellum (Fig. 2). Flagella enable some 
bacteria to move (motile bacteria), but all organisms which possess them 
are not motile, and under certain conditions bacteria without flagella may 
develop them, or organisms which possess flagella may lose the power to 
develop them. 



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Fig. 2. — Types of flagella. a, Vibrio cholera?, one flagellum at the end — monotrichia type; b, 
Bact. syncyaneum tuft of flagella at the end, rarely at the side — Lophotrichia type ; c, Bact. vulgare. 
flagella arranged all about — Peritrichia type (Lehmann and Neumann). 

Some bacteria, known as non- pathogenic, cannot grow and produce poison 
either in the tissues, in wound-fluid, or in the fluid moistening a mucous surface. 
Others grow upon dead organic matter, but are not able to invade living 
tissues. They can live and multiply in the discharge from a wound or in the 
fluid covering a mucous surface and are called saprophytes, saprophytic 
microbes, or putrefactive bacteria. Obligate saprophytes only live in dead 
matter and never become parasites. Facultative saprophytes can be parasites 
and can also grow in dead organic matter. Bacteria, known as the pathogenic, 
under certain conditions invade living tissue and cause various diseases. 
Parasitic bacteria can grow on or in the tissues of the body. Obligate parasites 
are those which have not been cultivated outside of the body (as the bacilli of 
leprosy) . Facultative parasites usually live outside the body, but may enter into 
the body and produce disease. The schizomycetes vary much in shape, size, 
color, arrangement, mode of growth, and action upon the body. One form can- 
not be transformed into another, but each maintains its specific identity. Every 
organism comes from a pre-existing organism, this being true of all forms. 
Pasteur proved that spontaneous generation is impossible. The protoplasm 
of these cells can be stained with anilin colors, and the cell-wall is more readily 
detected after treating it with water, which causes it to swell. 



20 Bacteriology 

Many bacteria are colored; others are colorless. Some move (motile 
bacteria); others do not move (amotile bacteria). The bacilli of anthrax 
and tuberculosis and all cocci are amotile. Most bacteria can change from 
motile to amotile, or from amotile to motile, when subjected to certain changes 
of soil and environment. The oscillations of cocci are physical in nature, 
not vital; they are Brunonian or Brownian movements, movements due to 
alterations in equilibrium because of currents or changes of level in the fluid 
in which the micro-organisms are contained. Bacteria seem to possess the 
power of attracting elements necessary for their nutrition (positive chemiotaxis 
or chemotaxis) and of repelling harmful elements (negative chemiotaxis or 
chemotaxis). 




Fig. 3.— Micrococci. Fig. 4.— Bacilli. Fig. 5.— Spirilla. 

Forms of Bacteria. — The three chief forms of bacteria are — 

1. The Coccus or Micrococcus — the berry-shaped, oval, or round bacterium 

(Fig. 3); 

2. The Bacillus — the rod-shaped bacterium (Fig. 4); 

3. The Spirillum or Vibrio — the corkscrew-shaped or spiral bacterium 
(Fig. 5). A short spiral organism is called a comma bacillus. 

De Bary compares these forms, respectively, to the billiard-ball, the lead- 
pencil, and the corkscrew. 

Cocci and Bacilli. — As surgeons we have to do only with cocci and bacilli. 
Cocci may be designated according to their arrangement with one another; 




Fig. 6. — SarciriEe forming ^bales of pack- Fig. 7. — Ascococcus Billrothii Colin (after F. 

ets. Single packets regularly grouped to- Conn), 

gether (Lehmann and Neumann). 

namely, when existing singly they are called monococci (Fig. 3); in pairs they 
are called diplococci (Fig. 8, a) ; arranged end to end in a chain they are called 
streptococci (Fig. 8, c); in group side by side clustered like a bunch of grapes 
they are called staphylococci (Fig. 8, b); in groups of four they are called 
plate cocci, or tetracocci; in cubical groups they are called sarcincc or wool-sack 
cocci (Fig. 6). Irregular masses, resembling frog-spawn, constitute zobglea 
masses (Fig. 9). The gelatinous matter in such a mass is formed by a trans- 
formation in the walls of the bacteria. The term ascococci is applied to a 
group of cocci enclosed in a capsule (G. S. Woodhead) (Fig. 7). 



Multiplication of Bacteria 21 

The cocci are often named according to their function, as, for example, 
" pyogenic," or pus-forming Cocci may be named according to the color of 
the culture. The name may embody the form, arrangement, color, and 
function; for instance, Staphylococcus pyogenes aureus signifies a round, 
golden-yellow micro-organism, which arranges itself with its fellows in the 
form of a bunch of grapes, and which produces pus. 



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Fig. S. — Forms of cocci. Fig. 9. — Zoogiea iBall.i. 

The bacilli are long, staff-shaped organisms. Long, delicate, jointed 
bacilli having wavy outlines are known as leptothrix forms. Chain-like bacilli 
are called streptobacilli. Bacilli give origin to many surgical diseases. 

Dichotomy or Branching. — It is very seldom that a side bud appears upon 
bacteria except in the bacteria of tuberculosis and diphtheria. 

Pseudodichotomy is by no means unusual. It occurs when one end of a 
bacillus grows by the end of the adjacent bacillus or when a bacillus in a chain 
divides in a line parallel to the chain and thus begins another chain (Fig. 10). 



J 



1 J J 



y 



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a 






Fig. 10. — Pseudodichotomy. a, In bacilli; 6, in streptococci (Lehmann and Neumann). 

.Multiplication of Bacteria.— Bacteria multiply with great rapidity 
when placed under suitable conditions. They can multiply by transverse 
fission or by spore-formation. Some bacteria multiply by both method-. In 
fission, or segmentation, a bacillus undergoes an increase in size and length ; 
a coccus does not increase in size but slightly elongates. In either case about 
the middle of the cell a transverse constriction begins, which deepens until the 
cell has divided into two parts, each of which soon grows as large as its parent 
(Figs. 11,12). As a rule, the micro-organisms separate after division of the 
cell; but they may not do so; and if they do not separate, the special grouping 



22 



Bacteriology 



receives a particular name (diplococci, streptococci, etc.)- If the division is in- 
variably in the same direction, and if the new cells remain in contact, strepto- 
cocci orstreptobacilli are formed. Tetracocci and sarcinae are formed when a 
number of cocci "divide in two or three successively vertical directions'^" Clin- 
ical Bacteriology," by Levy and Klemperer), forming four quadrants {tetra- 
cocci) or eight octants (sarcince). All cocci and some bacilli multiply by fission. 



Fig. ii. — Divisions of a micrococcus (after Mace). 



Fig. 12. — Divisions of a bacillus (after Mace). 

If segmentation of a single cell and the growth to maturity of its products re- 
quire one hour (it really takes place in less time, the cholera bacillus requiring 
but twenty minutes to divide), a single cell in a single day, if the conditions for 
increase were ideally favorable, would have 16,000,000 descendants, and 
in three days the mass of new cells would weigh 7500 tons (Cohn). In order, 
however, for such enormous multiplication to occur conditions would have to 
be absolutely favorable to the cells, and conditions are never absolutely favor- 
able. Were it otherwise, all other forms of life would be destroyed. During 
growth in a culture medium the products of bacteria are detrimental to the 
bacteria themselves. In a culture of cholera bacilli the number of living 
microbes begins to lessen after twenty-four hours, and after forty-eight hours 
the diminution is distinct. 

Spores. — A spore is a germ, and corresponds with the seed of a plant. 

Some bacilli, a few spirilla, and it may 
be sarcinae, multiply by spore-formation. 
Cocci do not undergo spore-formation 
after the manner of bacilli, though 
some observers maintain that cocci 
occasionally undergo an alteration that 
makes them very resistant to any 
destructive influences. When spore- 
formation is about to occur in a bacillus, 
a point of cloudiness or an area of 
bright refraction appears in the proto- 
plasm and the cell generally elongates. 
When a row of cells sporulate, the seg- 
ments, each of which contains a lustrous 
area or a region of cloudiness, look like 
parts of a necklace of beads (Fig. 13). 
The spore enlarges, the cell membrane bursts, and the young bacillus emerges 




Fig. 13. — Sporulation (after De Bary). 



Life-conditions of Bacteria 23 

through the opening. A cell usually contains but one spore, which may be 
situated at the end of the cell (ends pore) or in the middle of the cell (endospore). 
Sometimes a single cell contains several spores. If an endspore exists, the 
end of the cell containing the spore is swollen or club shaped (drumstick 
bacterium). If an endospore exists, the cell becomes spindle-shaped (clostri 
dium). When multiplication is by a single endospore, the bacillus does not 
elongate. When multiplication takes place by a process of combined spore- 
formation and fission, the mother-cell divides into a number of daughter-cells, 
which are called arthros pores. Organisms which when active multiply by 
fission take on spore-formation when subjected to certain conditions. 

Spore-formation tends to occur when bacilli are about to die for want 
of nourishment or when there is an excess of oxygen present. The spore 
has a dense envelope or covering which is very resistant to destructive agents. 
So resistant is the covering that twice the amount of heat is necessarv to kill 
a spore as to kill an active adult cell. Spores when placed under conditions 
unfavorable for development may remain inactive for an indefinite period, 
just as seeds remain inactive when implanted. When spores encounter favor- 
able conditions, they at once develop into adult cells, just as seeds develop when 
planted. It seems probable that spores occasionally remain dormant in the 
human body for long periods, and finally awaken into activity because of 
injury or disease of the tissue in which they lie. 

Chemical Composition of Bacteria. — The protoplasm of bacteria 
consists of water, salts, albuminous material, extractives soluble in alcohol, 
and extractives soluble in ether. 

Life=conditions of Bacteria.— In order to grow and to multiply, 
bacteria require a suitable soil and the favoring influences of heat and moisture. 
The soil demanded consists of highly organized compounds rather than crude 
substances, and slight modifications in it may prove fatal to some forms of 
bacterial life, but highly advantageous to others. Some organisms require 
albuminous matter, others need carbohydrates; they all require water, carbon, 
nitrogen, oxygen, hydrogen, and certain inorganic materials, especially lime 
and potassium (Woodhead). All organisms require water. If dried, no 
micro-organisms will multiply, and many forms will die. The fluids and 
tissues of the individual may or may not afford a favorable soil for the germs 
of a disease, or, in the same person, may afford it at one time and not at 
another. Some individuals seem to possess indestructible immunity from, 
and others are especially prone to, certain bacterial diseases. Impairment 
of health, by altering some subtle condition of the soil, may make a person 
liable who previously was exempt. Injury or disease of a tissue mav increase 
local liability. 

Again, some bacteria which under normal conditions are harmless may 
become virulent under certain conditions. Colon bacilli, which under nor- 
mal conditions seem to be putrefactive organisms inhabiting the intestine, may 
attack a point of least resistance in the intestine itself; this point being estab- 
lished by congestion, strangulation, inflammation, or injury, and descendants 
of the bacteria which attacked the point of least resistance may become so viru- 
lent that they can live and develop in tissues distant and apparently normal 
and cause disease in them. 

The presence of oxygen influences microbic growth. Most organisms 



24 Bacteriology 

thrive best when exposed to the oxygen of the air, and they are known as 
aerobic. The term anaerobic is employed to designate organisms that can 
grow and multiply and produce particular products only when air is absent, 
free oxygen being fatal to them. Tetanus bacilli and the bacilli of malignant 
edema are anaerobic. An organism which grows best in air but can grow when 
free oxygen is excluded is called a facultative-aerobic bacterium. It may need 
oxygen; but if it does, it is able to obtain it from the tissues when air is ex- 
cluded. A sensitive organism which dies when the amount of oxygen is even 
slightly diminished is called an obligate-aerobic bacterium. Most microbic 
diseases in man are due to facultative-aerobic bacteria. 

Effect of Motion, Sunlight, the X=rays, Cold, and Heat.— The ma- 
jority of fungi grow best when at rest; violent agitation retards the growth of 
some. Sunlight antagonizes the growth of certain bacteria, especially tubercle 
bacilli and the bacilli of typhoid fever. It is claimed by some that the .r-rays 
retard bacterial growth. Temperature influences bacterial growth. Some 
organisms will grow only within narrow temperature-limits, while others can 
sustain sweeping alterations, but most grow best between the limits of from 86° 
to 104 F. Freezing renders bacteria motionless and incapable of multiplica- 
tion, but it does not kill them: they again become active when the temperature 
is raised. Prudden showed that typhoid bacilli can live in ice one hundred 
and three days. The absurdity of employing cold as a germicide is evident 
when the fact is known that a temperature of 200 F. below zero is not fatal 
to germ-life, cell-activities by such a temperature only being rendered dor- 
mant. Bacteria have been placed in hermetically sealed tubes and the tubes 
immersed in liquid air for seven days. The germs were thus subjected to a 
temperature of — 190 C, but there was no change produced in their virulence 
(A. MacFayden and S. Roland, in " Lancet," March 24, 1900). High tempera- 
tures are fatal to bacteria; moist heat is more destructive than dry heat, and 
adult cells are more easily killed than spores. A temperature less than 212 
F. will kill many organisms, and boiling will kill every pathogenic organism 
that does not form spores. Some spores are not destroyed after prolonged 
boiling, and some will withstand a temperature of 120 C. As a practical 
fact, however, boiling water kills in a few minutes all cocci, most bacilli, 
and all pathogenic spores; though the spores of anthrax, tetanus, and ma- 
lignant edema are harder to kill than are the spores of other bacteria. 

Effect of Bacteria Upon Bacteria.— Some bacteria are antagonistic to 
others, some are synergistic to others. The streptococcus of erysipelas is 
antagonistic to the bacillus of anthrax and also to syphilis and tuberculosis. 
The growth of some microbes in culture-media makes a soil favorable or un- 
favorable for other microbes, and the same process may occur in the human 
body. Influenza, renders the lungs prone to infection with pneumococci. 
Saprophytes on mucous surfaces are antagonistic to certain pathogenic bacteria. 
We are not yet able to cure a microbic disease by inoculating the sufferer 
with antagonistic microbes, on the principle of sending a thief to catch a thief. 

Latent Bacteria. — Sometimes pathogenic organisms remain latent in the 
body for a considerable time. They are not destroyed but produce no symp- 
toms, or only local symptoms, possibly because the individual is immune for 
the time being. Pneumococci, staphylococci, and typhoid bacilli may become 
latent. Tubercle bacilli may remain latent in a lymph-gland. ' 



Antiseptic and Aseptic Agents 25 

Mixed Infection. — A fact of practical importance to the surgeon is 
that an area infected by one form of micro-organism may be invaded by 
another form. This is known as a mixed infection, and consists in a primary 
infection with one variety of organism, and a secondary infection with another, 
or in an infection at the same time with different micro-organisms. Mixed 
infection is especially common on surfaces exposed to air and wound in- 
fection is usually mixed. Koch found both bacilli and micrococci in the same 
lesion of tuberculosis. A soil filled with pneumococci favors the growth of pus 
cocci and tubercle bacilli. Tuberculous or syphilitic lesions may be attacked 
by erysipelas. Chancre and chancroid can exist together. A syphilitic ulcer 
is a good culture-soil for tubercle bacilli (Schnitzler). Suppuration in lesions 
of tuberculosis is due to secondary infection with pus organisms. Occasionally 
in empyema and other conditions due to pus organisms the diseased process 
ceases to be active, the pyogenic bacteria having lost much of their virulence, 
but a mixed infection with some germ usually harmless may break down sur- 
rounding barriers, intensify the virulence of bacteria, and aggravate the disease 
into an acute outburst. When secondary infection occurs the primary in- 
fection may remain, may be destroyed, or may be disseminated. 

Intrauterine or Placental Infection.— The infection of the embryo 
by the diseased ovum or the diseased sperm-cell occurs only in syphilis. Such 
an embryo is diseased at the first moment, of life. The direct transmission of 
bacteria from parent to fetus is a problem still in course of solution. Certain 
it is that some diseases may follow the transmission of the micro-organism 
through the septum of separation between the circulations of the mother and 
child. Placental transmission may occur in syphilis, scarlatina, pneumonia, an- 
thrax, measles, pyogenic conditions, and tuberculosis (Hektoen) . The transmis- 
sion of tuberculosis is very rare and few cases of congenital tuberculosis have 
been reported. Commonly, the bacilli are not directly transmitted from a tu- 
berculous mother to the embryo, the child is born free from tuberculosis but 
with weakened tissue-cells that easily fall a prey to the tubercule bacillus 
when it reaches them by any avenue. Placental transmission of bacteria 
is favored by disease or injury of the placenta. 

Chemical Antiseptics and Germicides and Aseptic Agents.— It is 
necessary to make a distinction between deodorizers, antiseptics, and ger- 
micides, although the two later terms are usually regarded as being interchang- 
able. In the methods of antiseptic surgery we use germicides. 

A deodorizer is an agent which destroys an offensive odor. It is true that 
an offensive odor may be due to microbic growth. It is also true that nasty 
odors may prove injurious to those who inhale them. But, nevertheless, the 
odor is the result of microbic action, and destroying an odor does not render 
harmless the bacteria which caused it. Charcoal is a well-known deodorizer. 

An antiseptic is an agent which retards or prevents putrefaction. It acts 
by weakening or killing saprophytic organisms, but is not fatal to spores. 

A germicide or disinfectant is an agent which is fatal to adult bacteria 
and spores. The destruction of the germs of the disease in clothing, in 
excreta, in a wound, etc., is known as disinfection. Disinfection of a wound, 
dressings, or instruments is called also sterilization. 

Antiseptics and germicides should not be used in clean wounds. Repair 
will occur more quickly if they are not used. Tillmanns has pointed out that 



26 Bacteriology 

when antiseptics are used cell-division is late in beginning and is slow in 
progress. Neither are germicides efficient in fatty tissue, as bacteria surrounded 
with oil cannot be reached by the drug, and the chemical is irritant and apt to 
cause fat necrosis (Haenel, in "Deutsch. mod. Woch.," 1895, No. 8). 

Corrosive Sublimate. — Many chemical agents will kill bacteria, one of 
the most certain of them all being corrosive sublimate. Koch showed that 
corrosive sublimate is an efficient test-tube germicide when present in the 
proportion of only 1 part to 50,000. It is used in surgery in strengths of 1 
part of the salt to 1000, 2000, 3000, or more parts of water. Badly infected 
wounds are occasionally irrigated with solutions of a strength of 1 to 500. 
Contact with albumin precipitates from a solution of corrosive sublimate an 
insoluble albuminate of mercury which forms a white layer upon the surface 
of the wound, is not a germicide, and prevents deep diffusion of the mer- 
curial fluid. In surgical operations by the antiseptic method the mercurial salt 
should be combined with tartaric acid in the proportion of 1 to 5, which 
combination prevents the formation of the insoluble albuminate of mercury. 

But though corrosive sublimate under certain conditions is extremely pow- 
erful, it is not always absolutely reliable. Many spores are very resistant to its 
action. Even a 1 per cent, solution of bichlorid of mercury is not certainly 
destructive to the spores of anthrax. Geppert tells us that anthrax-spores 
may be active after a twenty-five hour immersion in a 1 : 100 solution of 
sublimate (Schimmelbusch). In the presence of hydrogen sulphid corrosive 
sublimate is useless, inert and insoluble sulphid of mercury being precipitated; 
hence corrosive sublimate is without value as a rectal antiseptic; in fact, 
Gerloczy has proved that a concentrated aqueous solution of sublimate will 
not disinfect an equal quantity of feces. Corrosive sublimate contained in 
dressings after a time undergoes decomposition and ceases to be a germicide. 
It is not germicidal in fatty tissues because it is unable to attack bacteria 
which are coated with oil. Corrosive sublimate is very irritating to the tissues 
and causes copious exudation. Hence, after tissues have been irrigated with 
this agent drainage must be employed. In some cases the irritated tissues 
lose to a great extent their power of resistance to bacteria and infection may be 
actually facilitated by irrigation with sublimate. In rare instances corrosive 
sublimate is absorbed and produces poisoning. In spite of these shortcomings 
and drawbacks it is a valuable aid to the surgeon and must be frequently used, 
especially upon the skin of the patient and the hands of the operator and his 
assistants. It should be dissolved in distilled water, because ordinary water 
causes a precipitate to form (common salt prevents the formation of this 
precipitate). 

Because of the fact that corrosive sublimate is poisonous and very irritant, 
it should not be used upon serous membranes. It is absorbed quickly from 
serous membranes and destroys the endothelial cells and should not be in- 
troduced into the pleural sac, into joints, or into the peritoneal cavity. It 
should never be put within the dura, and should not be applied, in strong 
solution at least, to mucous membranes. It should not be introduced into the 
rectum for three reasons. First, it is intensely irritant and causes pain and 
inflammation. Second, it is useless, being largely and promptly converted into 
insoluble and inert sulphid of mercury. Third, a poisonous dose may be 
absorbed. Instruments cannot be placed in corrosive sublimate without being 



Carbolic Acid 27 

dulled, stained, and corroded. It is better to make the solution when it is 
needed, so as to have it fresh, for in old solutions much of the soluble corrosive 
sublimate has been converted into insoluble oxychlorid, and the fluid has 
ceased to be germicidal. In order to make up fresh solutions use tablets, 
each of which contains about 7 J grains of the drug — one of these tablets added 
to a pint of water makes a solution of a strength of 1 to 1000. Tablets which 
also contain ammonium chlorid are more soluble than those which contain 
corrosive sublimate only. Hot solutions of the drug are more powerfully 
germicidal than cold solutions. As corrosive sublimate is irritant, leads to 
profuse exudation, and may produce tissue-necrosis, it should never be in- 
troduced into an aseptic wound. In such a wound it can do no good and may 
do much harm. 

Griffin, in Foster's 'Practical Therapeutics," sets forth the strengths of 
solutions applicable to different regions: 

For disinfection of the surgeon's hands and the patient's skin, 1 : 1000; 
for irrigating trivial wounds, 1 : 2000; for irrigating larger wounds and 
cavities, 1 : 10,000 to 1 : 5000: for irrigating vagina, 1 : 10,000 to 1 : 5000; 
for irrigating urethra, 1 : 40,000 to 1 : 20,000; for irrigating conjunctiva, 
1 : 5000; for gargling, 1 : 10,000 to 1 : 5000. 

Corrosive Sublimate Poisoning. — Corrosive sublimate may be absorbed 
from a wound, a serous surface, or a mucous membrane, ptyalism and diar- 
rhea resulting. The absorption of bichlorid of mercury may be followed by 
cramp in the limbs and belly, feeble pulse, cold skin, extreme restlessness, and 
even collapse and death. At the first sign of trouble withdraw the drug and 
treat the ptyalism (page 291). 

Lithiomercuric Iodid. — This material was prepared and tested by Dr. 
Rosenberger and Mr. England ("American Medicine," 1904, page 1021). It is 
more powerfully germicidal than corrosive sublimate, it does not form inert 
albuminate when placed in a wound, and is not precipitated by alkalies. It 
is not nearly so irritant nor so poisonous as corrosive sublimate. I have 
given it an extensive trial in my clinic and am satisfied that it is superior to 
corrosive sublimate as a germicide and is far less irritant and poisonous. Its 
only objection is that it is more expensive. 

Carbolic Acid. — Carbolic acid is a valuable germicide in the strength of 
from 1 : 40 to 1 : 20. It is certainly fatal to pus-organisms, but weak solutions 
fail to kill most bacteria and do not destroy spores. Unfortunately, this acid 
attacks the hands of the surgeon; consequently in the United States it is chiefly 
employed as a solution in which to place the sterilized operating instruments, 
or as a germicide to prepare the skin of the patient before the operation is 
performed. 

Carbolic acid is very irritant to tissues, and carbolized dressings may be 
responsible for sloughing of the wound or dry gangrene. Because of its irritant 
properties wounds which have been irrigated with it should be well drained. 
Carbolic acid, like corrosive sublimate, is inert in fatty tissues. 

Pure carbolic acid is a reliable disinfectant for certain conditions. It is 
used to destroy chancroids, to purify infected wounds and abscess cavities, 
to disinfect the medullary cavity in osteomyelitis, to stimulate granulation after 
the open operation for hydrocele, or to purify sloughing burns or ulcerated 
areas. The pure acid rarely produces constitutional symptoms, but it occa- 



28 Bacteriology 

sionally causes sloughing. Its application causes pain for a moment only, 
and then analgesia ensues. Even dilute solutions of carbolic acid greatly 
relieve pain when applied to raw surfaces. The local action of carbolic acid 
can be at once antidoted by the application of alcohol (Seneca D. Powell). 
When carbolic acid is applied to a wound, the area about the wound should 
first be moistened with alcohol. After the application of pure carbolic acid 
to a joint, a wound, the medullary canal, or an infected area, the surgeon 
should wait about one minute and then apply alcohol. 

Carbolic acid acts more slowly and less certainly than corrosive sublimate. 
It requires twenty-four hours for a 5 per cent, solution to kill anthrax-spores. 
Pus or blood (albuminous matter) greatly weaken the germicidal power of 
carbolic acid, and fatty tissue cannot be disinfected by it. It is not even 
the best of agents in which to place instruments, as it dulls them. After 
operation upon the mouth it may be used as a wash or gargle, 1 to 2 per cent, 
being a suitable strength. It is used sometimes to irrigate the bladder and 
often to cleanse sinuses, but is not employed in the peritoneal cavity, the 
pleural sac, the rectum, or the brain. It is occasionally injected into tubercu- 
lous joints. Carbolic solution should never be used in clean wounds. 

Carbolic Acid Poisoning. — Carbolic acid is readily absorbed, and may thus 
produce toxic symptoms. Absorption is not uncommon when the weaker 
solutions are used, but seldom occurs . when a wound has been brushed over 
with pure acid, because the pure acid at once forms an extensive zone of co- 
agulated albumin, which acts as a barrier .to absorption. One of the early indi- 
cations of the absorption of carbolic acid is the assumption by the urine of a 
smoky, greenish, or blackish hue. This hue appears a little time after the urine 
has been voided, whereas the smoky hue of hematuria is noted in urine at once 
after it has been passed. The condition produced by carbolic acid is known as 
carboluria, and examination of such urine shows a great diminution or entire 
absence of sulphates when the acidulated urine is heated with chlorid of barium. 
The diminution of precipitable sulphates is explained by the fact that these 
salts are combined with carbolic acid, forming soluble sulphocarbolates 
(Griffin). Such urine is apt to contain albumin. If during the use of car- 
bolized dressing or the employment of carbolic solutions the urine becomes 
smoky, the use of the drug in any form must be at once discontinued, otherwise 
dangerous symptoms will soon appear. These symptoms are subnormal 
temperature, feeble pulse and respiration, muscular weakness, and vertigo. 
If death occurs, it is due, as a rule, to respiratory failure. The treatment of 
slow poisoning by carbolic acid consists in at once withdrawing the drug, 
giving stimulants and nourishing food, administering sulphate of sodium 
several times a day and atropin in the morning and evening. 

Saline Solution. — Sodium chlorid solution of normal strength (0.7 of r 
per cent.) does not damage the cells of serous surfaces or of a wound hence 
it is used as an irrigating fluid, and it is the best fluid for such a purpose. In 
intravenous infusion, in shock or hemorrhage it is very valuable. It does not 
damage the blood-corpuscles as plain water does. It is, however irritant to 
the kidneys, when used by hypodermoclysis or intravenous infusion; hence 
plain boiled water should be used for the former and saline fluid of one-half 
normal strength for the latter purpose. Normal salt solution is prepared as 
follows: A quart of water is filtered and sterilized and in this i| drachms 
of table salt are dissolved, and the fluid is again boiled. 



Iodoform 29 

Thiersch's Fluid. — This fluid is used upon mucous and serous surfaces 
and is employed to irrigate wounds. It is non-toxic and non-irritant. It 
consists of 1 grain of salicylic acid and 6 grains of boric acid to 1 ounce of water. 

Alcohol. — Alcohol is a germicidal agent, which is most powerful when of 
the strength of 70 per cent. It may be used on the hands or the skin of the 
patient, of a strength of from 70 per cent, to 95 per cent., and may be used 
plain or mixed with corrosive sublimate, of the strength of 1 to 1000. Pure 
alcohol is used to arrest the local action of pure carbolic acid. 

Boiled Water. — Is used to dissolve antiseptic materials; to inject by 
hypodermoclysis; to irrigate wounds, mucous cavities or serous surfaces, and 
as a fluid in which to keep instruments during the operation. It damages some- 
what the tissue-cells of the surface of a wound and injures the cells of serous sur- 
faces, hence for irrigation salt solution is to be preferred. 

Creolin, which is a preparation made from coal-tar, is a germicide without 
irritant or toxic effects. It is less powerful than carbolic acid, but acts similarly 
and is used in emulsion of a strength of from 1 to 5 per cent., and does not 
irritate the skin like carbolic acid. 

Peroxid of hydrogen is an excellent agent for cleansing a purulent or 
putrid area, but it is never applied to an aseptic wound. It is prepared in a 
10-volume solution, which should be diluted one-half or two-thirds before using. 
It probably destroys the albuminous element upon which bacteria live, and thus 
starves the fungi. When peroxid of hydrogen is applied to a purulent area 
ebullition occurs, liberated oxygen bubbling up through the fluid and the 
pus being oxidized. The peroxid reaches every cranny and diverticulum 
■containing pus. The peroxid of hydrogen is not fatal to tetanus bacilli; 
in fact, tetanus bacilli can be cultivated in a strong solution of it. It is very 
valuable as a mouth wash to cleanse the mouth before and after operations in 
the oral cavity. Some surgeons use it to wash out appendicular abscesses 
(R. T. Morris). It must not be injected into a deep abscess in any region 
unless a large opening exists, as otherwise the evolved gas may tear apart 
structures, dissect up the cellular tissue, and spread infection. The use of 
peroxid should not be too long continued, for if used for a considerable period- 
it makes the granulations edematous and retards healing. In fact, its con- 
tinued use may actually prevent a sinus closing. 

Iodoform. — Iodoform is largely used by surgeons in spite of the fact that 
laboratory workers have assured us it is not truly a germicide as bacteria will 
grow upon it. Clinical evidence, however, is in its favor and surgeons long ago 
concluded that it at least hinders the development of bacteria, directly antago- 
nizes the action of the toxic products of germ-life, and stimulates the pro- 
duction of connective tissue. It is of the greatest value when applied to putrid 
foci, suppurating areas, and tuberculous processes. In putrid foci it probably 
combines with toxins and renders them less poisonous or even inert. 

It attenuates the virulence of pus cocci and organisms of putrefaction. It 
renders its greatest service in tuberculous processes and is infinitely more 
powerful when oxygen is excluded than when it is present. The laboratorv 
workers who condemn it have in many cases used nutrient material in which 
it does not dissolve (P. F. Lomrv, "Archiv fur klin. Chir.," 1S96). D. B. 
Heile ("Proceedings of the German Surgical Congress of 1903") insists that 
iodoform is a valuable germicide if oxygen is excluded. He says, if iodoform 



30 Bacteriology 

is mixed with tissue juice, oxygen being excluded, the mixture becomes power- 
fully germicidal, even to streptococci in from three to five days, although neither 
constituent of the mixture when alone is germicidal. Tissue juice decomposes 
iodoform, liver juice decomposing it most rapidly, brain and fat decomposing 
it slowly. Granulation tissue decomposes it and tuberculous granulation 
tissue acts upon it most rapidly. 

The conclusion of Heile is that this study confirms the clinical observation 
that iodoform is valuable in cavities but not in free surfaces. My own 
belief is that it is more valuable in cavities than upon free surfaces, but 
when we are dealing with putrefactive areas, even on free surfaces, it 
is of great value. Heile maintains that when iodoform decomposes on 
a free surface it sets free I, which is not a powerful germicide. When it 
decomposes in tissue juice it sets free di-iod-acetylene, a powerful germicide 
which is rendered inert by oxygen. Clinically, no real substitute for iodoform 
has yet been found. It can be rendered sterile by washing with a solution of 
corrosive sublimate solution. It need not be applied to clean wounds, but the 
powder is very useful when dusted into infected wounds. It prevents wound- 
discharges from decomposing and distinctly allays pain. Gauze impregnated 
with iodoform is used to keep abscesses open after evacuation, to drain the 
belly after certain operations, to pack aside the intestines and prevent their in- 
fection during some abdominal operations, and as packing to arrest intra- 
cranial hemorrhage. Iodoform gauze will drain serum well, but will not drain 
pus. In fact, it blocks up a pus-cavity, and if retained long leads to the col- 
lection of purulent matter behind and about the supposed drain. If used in an 
abscess, it must be removed in twenty-four or thirty-six hours. Tuberculous 
joints and cold abscesses are injected with iodoform emulsion, which is made 
by adding the drug to sterile glycerin or olive oil. The emulsion contains 10 
percent, of iodoform. A solution in ether of a strength of 10 per cent, 
may be used to inject the cavity of a cold abscess, but it is dangerous, may 
rupture the wall, and is more apt to produce poisoning than is the emulsion. 

I odojorm-poisoning. — The drug must be used with some caution. Ab- 
sorption from a wound sometimes happens, producing toxic symptoms. 
These symptoms are frequently misinterpreted, being usually attributed to 
infection. R. T. Morris has pointed out that in iodoform-poisoning the 
wound seems to be in excellent condition, whereas in sepsis the wound is un- 
healthy. The symptoms in some cases are acute and arise suddenly, and 
consist of hallucinatory delirium, nausea, fever, watery eyes, contracted pupils, 
metallic taste in mouth, yellowness of the skin and eyes, an odor of iodoform 
upon the breath, the presence of the drug in the urine, the outbreak of a skin 
eruption resembling measles or one which is erythematous, vesicular, bullous, 
or petechial. There is often nephritis and always excessive loss of flesh and 
strength. Patients with such acute symptoms usually pass into coma and die 
within a week. Such attacks are most apt to arise in those beyond middle life 
(see Gerster and Lilienthal, in Foster's "Practical Therapeutics"). Iodin can 
be recognized :'n urine by adding a few drops of commercial nitric acid and a 
little chloroform. When the mixture is shaken the chloroform will take up the 
free iodin and become purple, and on standing the purple layer will settle to the 
bottom of the tube. Another method is as follows : Put a little urine in a saucer, 
add a little calomel, and stir. If the urine contains iodoform a brown color will 



Silver 31 

be noted (R. T. Morris). The finding of iodin in the urine, however, is not 
proof that the patient is poisoned. We may find it when no sign of poisoning 
exists. In chronic cases of iodoform-poisoning the first symptoms usually 
observed are moroseness, bewilderment, and irritability, followed by depression, 
with unsystematized persecutory delusions, delirium, coma, and even death. 

In systemic poisoning by iodoform, discontinue the use of the drug, sus- 
tain the strength of the patient, and favor the elimination of the poison. 

Iodoform sometimes produces greal local irritation of the cutaneous sur- 
face, the dermatitis being eczematous or else being manifested by crops of 
vesicles filled with turbid yellow serum or even bloody serum. These 
vesicles rupture and expose a raw oozing surface, looking not unlike a burn. 
The use of the drug must be at once abandoned, for to continue it will not only 
increase the dermatitis, but may produce constitutional symptoms. "Wash 
the vesiculated area with ether to remove iodoform, open each vesicle, and 
dress the part for several days with gauze wet with normal salt solution. After 
acute inflammation ceases apply zinc ointment or cosmolin. 

Aristol is an odorless iodin compound used by some as an antiseptic 
dusting-powder. 

Loretin is an antiseptic powder which is odorless, germicidal, non-irritant, 
and which is said to be non-toxic. 

Europhen is a powder containing iodin, and the iodin separates from 
it slowly when the powder is applied to wounds or burns. It does not produce 
toxic symptoms readily, if at all. and is a valuable substitute for iodoform. 
It is used especially in the treatment of ulcers and burns. 

Nosophen is a pale yellow powder containing 60 per cent, of iodin. Its 
bismuth salt is known as antinosin. Xosophen is not toxic, is free from 
odor, and is the best of the substitutes for iodoform. 

Acetanilid is frequently used as a substitute for iodoform. It is of value 
when applied to suppurating, ulcerating, or sloughing areas, but it does 
not benefit tuberculous conditions. Sometimes absorption takes place to a 
sufficient extent to cause cyanosis, sweating, and weakness of the pulse and 
respiration. If cyanosis arises, suspend the administration of the drug and 
administer stimulants by the stomach. 

Airol is a substitute for pure iodoform, and is composed of gallic acid, 
bismuth, and iodoform. It is non-irritant and non-toxic. 

Among other powders we may mention iodol, amyloform, subiodid of 
bismuth, and dermatol or subgallate of bismuth. 

Silver is a valuable antiseptic. Halsted and Bolton have shown that 
metallic silver exerts an inhibitive action upon the growth of micro-organisms 
and does not irritate the tissues. Crede has also demonstrated the same facts. 
These statements indicate one great reason why silver wire i> such a useful 
suture-material. Halsted is accustomed to place silver foil over wounds 
after they have been sutured, and Crede employs as a dressing a fabric in 
which metallic silver is intimately incorporated. 

Crede considers silver lactate (actol) an admirable antiseptic. It does 
not form an insoluble albuminate when introduced into the tissues and is 
not an irritant. Silver citrate (itrol) is said to be even a better preparation 
than silver lactate, and it is a useful dusting-powder. A preparation of 
metallic silver, known as colloidal silver or collar golum, is made. This prepa- 



32 Bacteriology 

ration is soluble in water and in albuminous fluids;, it remains as metallic 
silver when in solution, and is said to be powerfully germicidal. It certainly 
seems to cause leukocytosis and to stimulate phagocytosis. It comes put up in 
i and 2 grain tablets. A solution of the strength of from i to 5 per cent, is used. 
In severe cases of sepsis this solution is injected into a vein which 
has been rendered prominent by applying a bandage above the elbow. 
The dose is from 1 to 2 grains of the drug. One injection or more 
may be given. Some have given it subcutaneously, others by enema. 
Crede's ointment of silver is used in septic diseases and seems to be of value. 
In a child 15 grains, in an adult 45 grains of the ointment is rubbed in the 
skin at one time, and the rubbing should be kept up from ten to thirty minutes. 
There is said to be no risk of argyria. Protargol is a silver salt much used in 
gonorrhea. A solution in water is made. It is not precipitated by albumin, 
alkalies, nor acids. In gonorrhea a 1 to 5 per cent, solution is used. Argyrol 
is a new and valuable preparation of silver which I have used frequently with 
much satisfaction. It is known as silver vitelline, is not irritant, and contains 
30 per cent, of metallic silver. It is not precipitated by albumin. In a strength 
of 5 per cent, it is a very useful injection for gonorrhea, as it has powerful gono- 
coccidal properties. In some types of chronic cystitis several drams of a 3 per 
cent, solution may be injected into the bladder from time to time, and much 
stronger solutions can be used with safety. Inflamed mucous membranes may be 
painted with a solution of a strength of from 20 to 50 per cent. A sinus or a 
sluggish area of granulation may be stimulated by touching with a solution of a 
strength of from 25 to 50 per cent. I have found it of much service in sinuses. 

Formaldehyd, or formic aldehyd, has valuable antiseptic properties. 
Formalin is a 40 per cent, solution of the gas in water. Solutions of this 
strength are very irritant to the tissues, but 1 per cent, solutions can be used 
to disinfect wounds. A solution of a strength of 0.5 per cent, is used to 
irrigate sinuses, tuberculous areas, abscess-cavities, and suppurating joints. 
A strong solution is used to asepticize chancroids and other ulcers. A 2 
per cent, solution disinfects instruments. The vapor of formalin can be so 
applied as to disinfect wounds, and Wood suggests its employment in septic 
peritonitis as a means of disinfection after the abdomen has been opened. 
The vapor of formalin thoroughly disinfects catheters. 

Formalin-gelatin was introduced by Schleich as an antiseptic powder. 
The commercial preparation is known as glutol. When applied to a clean 
wound it gives off formalin and keeps the wound aseptic. When it is applied 
to a sloughing surface it will not give off formalin unless it is mixed with 
pepsin and hydrochloric acid. Formalin-gelatin has been used to replace 
bone-defects. 

Lysol is a clear, brownish, oily fluid with an odor like creasote. It is a 
valuable germicidal agent. It is saponified phenol and is used in a solution 
of a strength of from 1 to 3 per cent. It does not attack the hands like carbolic 
acid and is much less poisonous. 

Mustard is an excellent emergency germicide. Its value has been demon- 
strated by Roswell Park, who uses a mixture of soap, cornmeal, and mus- 
tard flour to scrub the surgeon's hands or the patient's skin. I have 
used it repeatedly with entire satisfaction. Mustard removes the odor of 
decay at once. 



Distribution of Bacteria 33 

Commercial gasolene is used by Riordan and others to clean wounds 
and ulcers, and to prepare the field of operation. Its vapor is so inflammable 
that the material must not be used when an artificial light is necessary, and 
it is used only in the daytime and on free surfaces where evaporation is rapid. 
It is sterile, non-irritant, and on evaporation leaves a dry, clean surface. 

Tincture of iodin maybe applied to an infected wound in the same manner 
as is pure carbolic acid; its use is advocated by Carl Beck. In dilute solution 
it is used to irrigate sinuses. The proper dilution for irrigation is obtained 
when the fluid is the color of sherry wine. 

'Nucleins, especially protonuclein, possess germicidal powers. Xuclein is 
composed of nucleinic acid and proteid material. When injected hypodermati- 
cally and to a less degree when taken by the mouth it increases the germicidal 
power of the blood-serum, causes leukocytosis and increased phagocytosis and 
thus prevents, or opposes infection. Mikulicz has used nucleinic acid to in- 
crease vital resistance as a preliminary to operation (page 40). A 1 per cent, 
solution of nucleinic acid is on the market. This acid is made from yeast. 
The dose of this preparation is from n]X to rnjx, hypodermatically, once or 
several times a day. Protonuclein probably contains nucleinic acid and is 
of some value when applied locally to areas of infection, particularly when 
sloughing exists. 

Heat. — The best germicide is heat, and the best form in which to apply 
heat is by means of boiling water (even better than steam). One can use 
boiling water upon instruments and dressings, but rarely upon a patient. 
Jeannel, of Toulouse, uses boiling salt solution in abscess-cavities, and 
some other surgeons employ steam or boiling water to disinfect the medullary 
canal in osteomyelitis. Nevertheless, boiling water is rarely applied to the 
patient, and in many cases a chemical germicide must be used. 

Among other antiseptics and germicides of more or less value we may 
mention trichlorid of iodin, chlorid of zinc, chlorid of iron, salol, oxycyanid of 
mercury, fluorid of sodium, argonin, sugar, lannaiol, bichlorid of palladium 
(in very dilute solution), thymol, potash soap, salicylic acid, boric acid, cam- 
phor, eucalyptol, cinnamon, bromin, chlorin (as gas or as chlorin-water), 
cinnamic acid, permanganate of potassium or of calcium, chlorate of potas- 
sium, and oxalic acid. The surgeon before operating should always scrub 
his hands in a germicidal solution. 

Distribution of Bacteria. — Microbes are very widely distributed in 
nature. They are found in all water except that which comes from very 
deep springs; in all soil to the depth of three feet; and in air, except that of 
the desert, that over the open sea, and that of lofty mountains. Dust free air 
does not contain them; the more dust the more microbes, hence they are present 
in greatest number in the air of towns. There are more in narrow courts than 
in broad highways, more in crowded rooms than in uncrowded apartments. 
Bacteria are present on the skin, in the alimentary canal, in the nose, 
mouth, and pharynx and in the blood and lymph. As Adami points out under 
normal conditions the bacteria which enter the blood are very quickly killed. 

Microbes may be be useful. Some of them are scavengers, and clean the 
surface of the earth of its dead by the process known as "putrefaction," in 
which complex organic matter is reduced to harmless gases and to a mineral 
condition. The gases are taken up from the air by vegetables, and the 



34 Bacteriology 

mineral matter is dissolved in rain-water and passes into the soil from which 
it came, there again to be food for plants, which plants will become food 
for animals. Other organisms purify rivers; others cause bread to rise; 
still others give rise to fermentation in liquors. Microbes may be harmful. 
They may poison rivers and soils; they may be parasites on vegetable life; 
they cause diseases of the growing vine, and also of wine; they produce the 
mould on stale, damp bread; they occasionally form poisonous matter in 
sausages, in ice-cream, and in canned goods; and they produce many diseases 
among men and the lower animals. 

With so universal a distribution of these fungi, man must constantly take 
them into his organism. They are upon the surface of his body, he inhales 
them with every breath, and he swallows them with his food and drink. 
Most of them, fortunately, are entirely harmless; others cannot act on the 
living tissues; but some are virulent, and these are generally, but not always, 
destroyed by the cells of the human body. The alimentary canal always 
contains bacteria of putrefaction, which act only upon the dead food, and not 
upon the living body; but when a man dies these organisms at once attack 
the tissues, and post-mortem putrefaction begins in the abdomen. 

Koch's Circuit. — To prove that a microbe is the cause of a disease it 
must fulfil Koch's circuit. It must always be found associated with the 
disease; it must be capable of forming pure cultures outside the body; these 
cultures must be capable of reproducing the disease; and the microbe must 
again be found associated with the artificially produced morbid process. 

Disease Production. — Pathogenic organisms cannot enter through the 
sound skin and the unbroken skin without causing the formation of lesions 
at the point of entrance. The sound skin is the very best antiseptic covering 
for tissue, as ordinary bacteria cannot pass it at all. Some bacteria by entering 
the ducts of cutaneous glands may cause disease. Disease-producing organ- 
isms which enter the body may reach the focus in which they act from outside 
of the body, entering by inoculation, inhalation, or ingestion. In most in- 
stances organisms which enter the body from without are rapidly destroyed. 
When they enter in large numbers, or when they are very virulent, or when the 
vital resistance of the individual is at a low ebb they cause disease. Bacteria 
may reach the region in which they become active from some other part of the 
body. Bacteria seldom dwell in the body long without inducing disease, but 
spores can lie dormant in the system for years. When bacteria or spores from 
some other part of the body reach a region of injury or disease they may be- 
come active; this area is a damaged and weakened part, in it the circulation 
is abnormal, it is a so-called point of least resistance (a locus minoris resistenticc) 
which affords a nest for them to develop and to multiply, the cellular activities 
of the weakened part being unable to cope with the activities of the germs. Even 
large numbers of pathogenic organisms may induce no trouble in a healthy 
man; but let them reach a damaged spot, and mischief is apt to arise. Kocher 
established subcutaneous bone-injuries in dogs, and these injuries pursued 
a healthy course until the animal was fed upon putrid meat, whereupon suppu- 
ration took place. This experiment proves that micro-organisms can reach 
a damaged area by means of the blood, and it enables us to understand how 
a knee-joint can suppurate when we merely break up adhesions, and how 
osteomyelitis can follow trauma when the skin is intact. A given number 



Ptomai'ns 35 

of organisms might produce no effect on a healthy man, whereas the same 
number might produce disease in an individual who was weak or ill-nourished, 
suffering from depression or fear, or debilitated by the habitual use of alcohol. 
The personal equation plays a great part in disease-production. Some indi- 
viduals seem to be immune to certain diseases; and these immunities and 
liabilities may be hereditary or acquired, temporary or permanent. 

Enzymes. — Bacteria contain and excrete ferments, and these ferments 
are known as enzymes. Bacterial ferments resemble pepsin and trypsin, the 
digestive ferments. The digestive ferments convert albumin into peptone, 
starch into sugar, and break up fat. When microbic infection of the tissues 
occurs the enzymes of the bacteria act upon the tissues just as the digestive 
ferments act upon the food, and form microbic albumoses. The enzymes 
are the weapons of micro-organisms. By means of these ferments bacteria 
not only prepare substances for assimilation, but seek to destroy antagonists 
and cell enemies. It is probable that enzymes when absorbed are frequently 
productive of toxemia. 

Toxins. — The action of pathogenic bacteria upon the tissues is of great 
importance. In the first place, they abstract from the blood, the lymph, 
and the cells certain elements necessary to the body, — as water, oxygen, 
albumins, carbohydrates, etc., — and thus cause body- wasting and exhaustion 
from want of food. In the second place, bacteria produce a vast number 
of compounds, some harmless and others highly poisonous. The symptoms 
of a microbic disease are largely due to the absorption of poisonous materials 
from the area of infection. These poisons may be formed from the tissues 
by the action upon them of the bacteria (true toxins and peptones) or may be 
liberated from the bodies of degenerating microbes (bacterial proteid or endo- 
toxins). Bacteria contain and secrete ferments; and as albumoses are formed 
in the alimentary canal by the action of digestive ferments upon proteids, sugars, 
and starches, so microbic albumoses are formed by the action of microbic 
ferments upon tissues. Just as the albumoses formed in digestion are poisonous 
when injected, so the albumoses of microbic action are poisonous when ab- 
sorbed. The albumoses of microbic action are called toxalbumins, and these 
albumoses often operate as virulent poisons to the body-cells. 

A number of compounds formed by the microbic destruction of tissue are 
alkaloidal in nature. These poisonous alkaloids are readily diffusible and, 
many of them, very virulent. It is probable that every pathogenic organism 
has its own special toxin which produces its characteristic effects, although 
the effects are modified by the nature of the soil — that is to say, by the condi- 
tion of the tissues. Again one micro-organism may produce several toxins. 
The absorption of toxins may be very rapid; for instance, the toxins of cholera 
may kill a man before the bacilli have migrated from the intestine. Brieger 
uses the term toxin to designate all of the poisonous products of bacterial action. 
He divides toxins into alkaloidal or crystallizable and amorphous, the latter 
being called toxalbumins. 

Ptomains. — By many writers the term "ptomai'n" is used to designate 
these toxins, but in reality a ptomai'n is a form of toxin produced by the 
action of saprophytic bacteria. A ptomai'n is a putrefactive alkaloid, and a 
toxin is any poison of microbic origin. Among these putrefactive alkaloids 
may be mentioned tetanin, typhotoxin, sepsin, putrescin, tyrotoxicon, muscarin, 



36 Bacteriology 

and spasmotoxin. The poison which occasionally forms in cheese, ice-cream, 
sausage, and canned goods is composed of ptoma'ins. Poisoning by any 
putrid food is called ptoma'in-poisoning. 

LeukomaiVlS must not be confounded with the above-mentioned bodies. 
Leukoma'ins are alkaloidal substances existing normally in the tissues not 
produced by bacteria but arising from physiological fermentations or re- 
trograde chemical changes. They are natural body-constituents, in contrast 
to toxins, which are morbid constituents. Leukomai'ns are found in ex- 
pired air, saliva, urine, feces, tissues, and the vemon of serpents. If not 
excreted, these bodies may induce illness, and when injected may act as 
poisons. Ordinary colds and some fevers result from leukoma'ins; they 
play a great part in uremia, and when excretion is deficient the retained 
leukoma'ins make the system a hospitable host for pathogenic bacteria. 
Sickness due to the retention and absorption of leukoma'ins is known as 
auto-intoxication. Among leukoma'ins may be mentioned adenin, hypoxan- 
thin, and xanthin, allied to uric acid, and other substances allied to creatin 
and creatinin. The surgeon should never forget the possibility of harm being 
done by retained leukomai'ns, and should endeavor to prevent autointoxication 
in all cases by keeping the skin, the bowels, and the kidneys active. 

Immunity. — If a person cannot be infected with a certain disease, he 
is said to be immune. Some persons seem naturally immune to certain dis- 
eases. Immunity to some diseases may be produced artificially. It has long 
been known that when a person recovers from certain diseases he has be- 
come immune to the disease from which he suffered. Immunity may be 
transitory, prolonged or permanent. Acquired immunity may be compared 
to fermentation. When fermentation ceases, the addition of more ferment is 
without result. When a person recovers from certain diseases, the addition 
to his blood of more of the causative bacteria is also void of result. 

Alexins and Antitoxins. — Immunity was long believed to arise from 
the exhaustion of some unknown constituent of tissue necessary to the life of 
the bacteria. This theory was advanced by Pasteur. It has been abandoned 
because of the demonstration that though an animal may be immune to certain 
bacteria, these bacteria will grow in its blood or tissue. A theory proposed 
by Chauveau is known as the "retention theory," and is the opposite of Pas- 
teur's "exhaustion theory." According to Chauveau, bacteria growing within 
the body leave as a legacy excrementitious material, and the accumulation 
and retention of excrementitious products produce immunity. 

At the present time there are two notable theories of immunity, and it is 
probable that each is at least partly true. The first theory is that of phago- 
cytosis, which assumes that certain body-cells attack, consume, and destroy 
bacteria (see below). The other theory is founded on the discovery of Nuttal 
and Euchner that normal fresh blood-serum is germicidal, the power varying 
for different bacteria and being limited. A fixed amount of serum is capable 
of destroying a fixed number of bacteria of a certain variety. Vaughan and 
others have shown that the germicidal agent is probably a nuclein furnished 
chiefly by the white cells and held in solution by the alkaline serum. This 
germicidal agent Buchner called "alexin" or defensive proteid, and explained 
immunity by its presence. This theory is known as the "humoral theory." 
According to this theory, when an animal is naturally immune to a bacterial 



Alexins and Antitoxins 37 

disease it is assumed that the blood-serum and body-fluids contain enough of 
this alexin to dissolve or destroy the bacteria. In all probability both phago- 
cytosis and bacterial solution are occurring in the same patient at the same 
time, phagocytosis being impossible but for the serum and bacteriolysis being 
impossible without leukocytes. 

Since the above discoveries were made it has been found that when an 
animal recovers from some bacterial diseases the blood-serum and body-fluids 
contain a new protective substance which is not an alexin, but which has the 
power cf destroying the toxins of the bacteria. It is known as an antitoxin 
and is produced by the body-cells under the stimulation of true soluble bacterial 
toxins. The first antitoxin to be discovered was that of diphtheria. The dis- 
covery was made by Behring in 1890. He found that if an animal is injected 
with gradually larger amounts of toxin of diphtheria the serum comes to contain 
an antitoxic material. Very soon after this discovery was announced Behring 
and Kitasato made a like discovery in regard to tetanus toxin. It is thus seen 
that bacteria not only produce poisons, but also stimulate the body-cells to 
produce antidotes to these poisons. Alexins exist in normal blood and kill 
bacteria. Antitoxins exist in blood of animals rendered immune and do not 
kill bacteria, but simply neutralize their toxins. An antitoxin combines with a 
toxin, and renders it inert and keeps it from combining with cells for which it 
has a special preference. It was pointed out by Kitasato and Behring that 
animals can be rendered immune to tetanus by artificial means and that the 
blood-serum of immune animals will, if injected into other animals, render 
them immune, or perhaps cure the disease if injected into animals suffering 
from tetanus. The same statements were also proved to be true of diphtheria. 
Now many experimenters are endeavoring to find the antitoxin of each microbic 
disease for the purpose of using it therapeutically and also as a preventive agent. 

The real mechanism of antitoxin-formation is unknown, although it seems 
certain, as Roux maintains, that it is secreted by the body-cells. 

Ehrlich's theory of the mechanism of immunity is at present attracting 
much interest. His theory may be explained in the words of D. H. Bergey 
("American Medicine," Oct. 11, 1902). 

"In the light of our later knowledge upon the subject, Ehrlich, in 1898, 
formulated his hypothesis of the mechanism of immunity which is receiving 
very general acceptance by scientists to-day. His theory of the mechanism 
of immunity is based upon Weigert's teaching of the process of tissue repair. 
It is a matter of universal observation that nature is prodigal in her attempts 
to repair an injury. This is shown in the healing process in an ordinary 
wound. A much larger amount of material is thrown out to bridge the chasm 
than is really utilized in the formation of new tissue. The presence of an 
excessive amount of new material is shown by the fact that the part is raised 
above the level of the surrounding sound tissue, and this excess is removed 
gradually as the new-formed tissue becomes stronger and stronger, until 
finally the wound is marked by a line of white scar-tissue, the excess gradually 
passing into the blood-current. 

"Ehrlich believed that the mechanism of immunity was explainable on a 
similar basis. It had become evident from the experiments of Washerman 
with the tetanus bacillus that its toxin had an especial affinity for the cells 
of the central nervous system. Experiments with other bacteria pointed to 



38 Bacteriology 

the fact that the toxins of different species of bacteria had an especial affinity 
for the cells of different organs of the body. When the amount of poison 
entering the body is insufficient to destroy the cells which have an especial 
affinity for it, these cells may be injured only to such an extent as to permit 
subsequent repair. In order to comprehend Ehrlich's hypothesis it is neces- 
sary to conceive the cells of the body as having a complex structure which 
may be stated diagrammatically as consisting of a central mass or nucleus 
from which radiate a number of 'lateral chains,' or bonds, each of which 
serves to bind the cell to other substances. In the case of the cells of the 
central nervous system one of these lateral bonds has an especial affinity 
for tetanus toxin and suffers destruction. The cell now finds itself in unstable 
equilibrium, and at once proceeds to repair the damage wrought. As in the 
case of tissue repair, the new material produced is far in excess of the required 
amount. The excess finds its way into the blood-current. This material 
now circulating in the blood-current has the same affinity for tetanus toxin as 
when united with the central mass of a cell as its lateral bond, and can, there- 
fore, combine with tetanus toxin floating in the blood-current, thus preserving 
other cells from injury. The union formed between the lateral bond of the 
cell (which is really the antitoxin) and the tetanus toxin results in the forma- 
tion of a compound which is physiologically inert. According to Ehrlich's 
idea, therefore, the antitoxin is simply the excess of lateral bonds floating 
in the blood-current. This substance can neutralize the effect of the tetanus 
toxin in a test-tube just as readily as it does within the body." 

In some infections soluble toxins are not formed and the body resistance 
depends largely on the formation by the bacteria of substances which finally, 
when present in sufficient amount, destroy bacteria. 

Phagocytes. — It was generally believed after Metschnikoff's important 
discoveries that leukocytes were the agents which protected the body from 
infection. 'When other observers found that in blood-serum is material that 
damages or destroys bacteria, opinion swung to the view that the blood-serum 
contains the protective element, and that the leukocytes are simply scavengers 
and remove dead bacteria but do not destroy living ones. It has recently been 
shown that under some circumstances leukocytes destroy living bacteria 
and under other circumstances they do not and that the presence or absence of 
this property depends upon the presence or absence in the blood-serum of sub- 
stances which act upon bacteria and render them susceptible to the phago- 
cytic action of leukocytes. The existence of these substances was demon- 
strated by Wright and Douglas in 1903, and they named them opsonins. If 
opsonins are present, they act upon bacteria, and render the bacteria susceptible 
to phagocytosis. (SeeLudvigHektoenin" Jr. Am. Med. Assoc," May 12, 1906.) 
The source of opsonins is not known but serum normally contains "opsonins 
for many different bacteria "(Hektoen, in "Jr. Am. Med. Assoc," May 12, 1906) . 
When experiment determines the fact that an individual's leukocytes are 
highly phagocytic toward particular bacteria, we believe that a quantity of 
opsonin for that variety of bacteria is present, and we may say the individual 
has a high opsonic index as regards them. Under opposite condition we say 
he has a low opsonic index. The tendency of the white blood-cells, and in a 
less degree of the endothelial cells of the blood-vessels, lymph-spaces, and lvmph- 
channels, to destroy bacteria under certain circumstances is undoubted. 



Artificial Stimulation of Phagocytosis 



39 




This process of destruction is known as phagocytosis, and the destroying cells 
are called phagocytes. When infection occurs, the white blood-cells gather 
in enormous numbers at the seat of disease, encompass and surround the 
bacteria, and build a barrier to prevent dissemination of the microbes and 
general infection of the organism. The force which draws leukocytes to a 
region of infection also tends to draw them to an area where there is cellular 
degeneration or death. This force is called positive chemiotaxis and is greatly 
stimulated by opsonins. In very virulent infections the leukocytes may fail 
to collect and may actually be repelled and scattered under the influence of 
what has been called negative chemiotaxis. Phagocytes at the seat of infection 
try to eat up, carry away to a gland, and there digest and destroy bacteria. 
A battle royal occurs, the microbes fighting the body-cells with most active fer- 
ments and destroying the opsonic power of the blood-liquor; the body-cells en- 
deavoring to devour and destroy the bacteria (Fig. 14), in which effort opsonins 
give them aid. In some cases the bacteria win absolutely and the patient 
dies. In other cases they win 
for a time and overwhelm the 
system; but presently the 
body-cells, whose movements 
were inhibited by the poison, 
regain their activity and are 
now immune to the bacterial 
poison. It is probable that 
the materials thrown out by 
the white cells during the 
combat with the microbes tend 
to destroy bacterial products 
and to neutralize toxic prod- 
ucts of tissue destruction. 
These materials, which neu- 
tralize toxic products are 
known as antitoxins (page 36). After the attack of disease has passed away 
the body-cells have been educated to withstand this poison, and new cells in 
the future retain this capacity; the weak cells were killed, the fittest survived, 
and the body fluids contain antitoxin. The new cells formed in the body 
are insusceptible to the poison and the individual is said to be insusceptible 
or immune. The theory of phagocytosis immunity assumes an educated 
white corpuscle and body-cell. This view originated with Sternberg, but it is 
usually accredited to Metschnikoff. Lankester gave us the term "educate 1 
corpuscle." 

Artificial Stimulation of Phagocytosis.— When active hyperemia is 
induced by heat, when irritants are applied to an inflamed surface, or when 
an inflamed joint is treated by Bier's method of passive hyperemia, local 
leukocytosis is stimulated and phagocytosis becomes more active. Some ten 
years ago Issaeff affirmed that the introduction of certain materials, as salt 
solution, into the peritoneal cavity, leads, for a time, to great increase in the re- 
sistance to abdominal infection. This period of increased resistance he called 
the resistance period. It begins a few hours after the injection and terminates 
by the end of the fifth day. During this period the great increase in intra- 




Fig. 14. — Phagocytosis: 



A, Successful; 
(Senn). 



B, Unsuccessful 



40 Bacteriology 

peritoneal leukocytes saves the animal from infection with bacteria which 
would otherwise cause a dangerous or fatal inflammation. Mikulicz believed 
it possible to establish this resistance period before abdominal operations and 
was working on the problem just before his lamented death. Mikulicz used 
diluted nucleinic acid (Mikulicz, " Verhandl. d. 33. Congress d. Deutsch. Ges 
f. Chir.," 1904). The agents used must not be of a nature to damage opsonins, 
for leukocytosis without plenty of opsonins would do no good. 

Vital Resistance. — It is learned from the above that the vital resistance 
to infection depends in part upon germicidal and opsonic blood-liquor and in 
part upon active leukocytes. 

Vital resistance is increased by agents which cause active phagocytosis 
(see nucleinic acid, page 33) without destruction of opsonins. 

Anything that lessens the germicidal and opsonic power of blood-serum or 
the phagocytic activity of corpuscles lessens vital resistance. Among these 
causes are ill health, worry, unhygienic life, chronic drug intoxications, chronic 
visceral diseases, diabetes, Bright's disease, gout, rheumatism, violent and 
sudden fluctuations of temperature, and the creation of points of least 
resistance (page 34). 

Protective and Preventive Inoculations.— Our knowledge of pro- 
tective inoculations for contagious diseases dates from Jenner's discovery 
of vaccination against smallpox in 1798. Preventive inoculations with attenu- 
ated virus are due to the experiments of Pasteur. This observer discovered 
the cause of chicken-cholera, and cultivated the micro-organism of this disease 
outside the body. He found that by keeping his cultures for some time they 
became attenuated in virulence, and that these attenuated cultures, inoculated 
in fowls, caused a mild attack of the disease, which attack was protective, and 
rendered the fowl immune to the most virulent cultures. Cultures can be 
attenuated by keeping them for some time, by exposing them for a short period 
to a temperature just below that necessary to kill the organisms, or by treating 
them with certain antiseptics. It has further been shown that injection of the 
blood-serum of an animal rendered immune by inoculation is capable of mak- 
ing a susceptible animal also immune. 

A most important fact is that animals may be rendered immune to certain 
diseases by inoculating them with filtered cultures of the microbes of the dis- 
ease, the filtrate containing microbic products, but not living microbes. Bv 
this method animals can be rendered immune to tetanus and diphtheria. 
Pasteur's protective inoculations against hydrophobia owe their power to 
microbic products, and Koch's lymph contains them as its active ingredients. 
The chief feature in acquired immunity is the presence in the blood and 
tissues of elements which can neutralize the toxic products of bacteria. These 
elements are " antitoxins " (page 36) . Microbic products are dead and cannot 
multiply as can living bacteria, hence the human organism is not overwhelmed 
unless the dose is too large, but the microbic products cause the development 
of antitoxin as certainly as do the living microbes. The above facts are of 
immense importance, for on these lines may be solved the problems of the 
prevention and treatment of microbic maladies. 

Orrhotherapy, or serum=therapy, is an attempt to utilize therapeu- 
tically the germicidal properties of blood-serum. It is believed that when 
a person recovers from an infectious disease the alkaline blood -serum is 



Orrhotherapy, or Serum-therapy 41 

saturated with protective material known as antitoxin. If this belief is true, it 
is a proper deduction that blood-serum containing protective material should 
cure the disease if injected into a patient suffering from an attack. Instead of 
using the blood-serum itself, some observers have precipitated the supposed 
curative material from the serum, have dissolved this material, and have ad- 
ministered the solution in fixed amounts. Instead of using the serum of per- 
sons rendered immune by an attack of the disease, many physicians have em- 
ployed the serum of animals rendered artificially immune by injections of 
attenuated cultures of the bacteria or injections of bacterial products. Some 
experimenters have even employed the serum of animals naturally immune 
to the disease. In some cases the serum is given hypodermatically, in some 
intravenously, in some by lumbar puncture, in some by intracerebral, and 
in others by intraneural injection. That Pasteur has devised a method which 
will usually prevent hydrophobia is certain (page 270), and that Murri, of Bo- 
logna, has cured a case of hydrophobia seems proved (page 271). Hosts of ob- 
servers believe in the utility of tetanus antitoxin and diphtheria antitoxin. 
The earlier in the disease the injection of antitoxin is practiced and the larger 
the dose the more apt it is to prove curative. When the toxin has not yet com- 
bined with cells antitoxin may keep it from doing so, and when it has recently 
combined and the combination is still unstable, antitoxin may cause disasso- 
ciation of the combination. When the disease is well established the cell 
combination of toxin is firm and antitoxin will in all probability fail to 
cure. 

Inconclusive experiments have been made in the treatment of syphilis 
by the serum of dog's blood, and by the blood-serum of men laboring under 
tertiary syphilis; in the treatment of pneumonia with the blood-serum of 
persons convalescent from pneumonia; and in the treatment of sufferers 
from septic diseases with antistreptococcic serum — blood-serum of animals 
rendered immune to septic infections. The real value of antistreptococcic 
serum is as yet uncertain. Occasionally it seems to do great good; at other 
times it appears to produce no benefit whatever. In several cases of phleg- 
monous erysipelas and in two cases of malignant endocarditis I thought it was 
of benefit. Tavel, in a recent elaborate research (" Klinische-therapeutische 
Wochenschrift " (Vienna), August, 1902), states that he obtained brilliant 
results in some cases, but no results in others. He does not undertake to 
explain this variability of action. He thinks the serum benefits staphylo- 
coccus as well as streptococcus infections. Malignant tumors (both sarcomata 
and carcinomata) have been treated with the blood-serum of dogs, which 
animals had been injected with fluid expressed from malignant growths 
(Richet and Hericourt). Von Leyden and Blumenthal obtain a serum by 
compression of a recent cancerous growth and treat human victims of cancer 
with it. They claim that the results are encouraging (" Deutsche medicinishe 
Wochenschrift," Sept. 4, 1902). Many claims made for serum-therapy in 
surgical diseases are exaggerated, sensational, and unscientific. It does not 
seem possible to obtain an antitoxin for each bacterial malady and the bacteria 
of most specific diseases are potent for harm for more reasons than because they 
form crystalloidal toxic matter. That there is truth in the method seems 
highly probable, but how much truth there is, is not yet definitely ascertained. 
It is our duty to study, experiment, and observe, and to reach a conclusion 



42 Bacteriology 

only after honest, careful, and thorough investigation. A little skepticism is as 
yet a safe rule. 

Special Surgical Microbes.— Suppuration (seepage 127). — Suppura- 
tion is caused by microbes. Does it ever exist without them ? The answer is, 
"Practically no." Injection of a sterile fluid containing dead organisms, or 
the injection of the sterile products of the growth of pyogenic cocci, will form a 
limited amount of pus; injection of an irritant forms a thin fluid which may re- 
semble pus, but which is not pus. In surgery pus is very seldom met with with- 
out the actual presence of micro-organisms (page 128), and the presence of pus 
proves the presence of micro-organisms. 

Pyogenic Bacteria. —Pus microbes, or pyogenic microbes, are strongly 
proteolytic, that is, they possess the property of peptonizing albumin, and 
thus forming pus. The peptonizing action is brought about by bacterial 
products. Some believe that pus is not formed by a peptonizing action of 
the bacteria but that the bacteria furnish a poison (leukolysin) which breaks 
up the leukocytes, and that the breaking up of leukocytes liberates an enzyme 
which dissolves albumin. The inflammation which surrounds an area of 
pyogenic infection is caused by the irritant products of bacterial action (tox- 
albumins, ammonia, etc.). In the presence of the pyogenic peptones the 
coagulation of inflammatory exudate is retarded or prevented. Bacteria 
which ordinarily cause suppuration may not cause it but produce non-sup- 
purative inflammation if they are present in small numbers or if the tissue re- 
sistance is at a high level, or if their virulence has been modified by adverse 
antecedent conditions. Bacteria which ordinarily do not cause suppuration 
may do so under certain conditions of increased bacterial virulence or lessened 
tissue resistance. The typhoid bacillus is at times pyogenic, but, as a rule, 
it is not pyogenic. The usual causes of suppuration are the following micro- 
organisms. 

The term micrococcus pyogenes (Fig. 15) includes the staphylococcus 
aureus, the staphylococcus albus, and the staphylococcus citreus. These 
forms are deviations from one form and are not specifically different. 
The albus and citreus may be grown from the aureus and they may 
remain white and yellow or may revert in part to the aureus form ("Atlas of 
Bacteriology," by Lehmann and Neumann). Some observers maintain that 
these forms vary greatly in virulence and hence are specifically different, but 
the varying virulence has been disputed and it seems to have been proved that 
virulence may be lessened greatly even when the color does not change. Sev- 
enty-seven per cent, of acute abscesses are due to staphylococci (W. Watson 
Cheyne). Staphylococci are found also in osteomyelitis, in a carbuncle, in a 
boil, in acne, in pemphigus, in periostitis, in septicemia, and in pyemia, and 
in some cases of empyema and peritonitis. 

Staphylococcus pyogenes aureus (Plate 1, Fig. 1, and Fig. 15), the golden- 
yellow coccus. When grown in the air it produces orange-yellow pigment. 
This is the most usual cause of abscesses (circumscribed suppurations). The 
staphylococcus pyogenes aureus grows best in air but can grow when air is ex- 
cluded. As it can thus grow it is a facultative, aerobic parasite. It is widely 
distributed in nature, and is found in the soil, the dust of air, water, the ali- 
mentary canal, under the nails, on and in the superficial layers of skin, 
especially in the axilla? and perineum, in the mouth, the nasal cavities, the 



Special Surgical Microbes 43 

vagina, and human milk. It forms the characteristic color only when it 
grows in air (Plate i, Fig. i). It is killed in ten minutes by a moist tem- 
perature of 58 C, and is instantly killed by boiling water. Carbolic acid 
(1 : 40) and corrosive sublimate (1 : 2000) are quickly fatal to this coccus. 

Staphylococcus pyogenes albus (Plate 1, Fig. 2), the white staphylococcus, 
acts like the aureus, but is usually more feeble in power. When this organism 
is found upon and in the skin it is called the staphylococcus epidermidis albus, 
an organism which Welch proved to be the usual cause of stitch-abscesses. 

Staphylococcus pyogenes citreus, the lemon-yellow coccus, is found occa- 
sionally in acute circumscribed suppurations, but less often than are the 
other two forms. Its pyogenic power is even weaker than that of the albus. 

The staphylococcus cereus albus and the staphylococcus cereus flavus are 
found occasionally in acute abscesses, but these forms cannot be sharply dif- 
ferentiated from the micrococcus pyogenes and the names should be abandoned. 

Staphylococcus flavescens is occasionally found in abscesses. It is inter- 
mediate between the aureus and albus (Senn). 

I , "*■ 

Fig. 15.— Micrococcus pyogenes aureus (X iooo). Fig. 16.— Streptococcus pyogenes (X 7°°)- 

(Lehmann and Neumann.) (Lehmann and Neumann.) 



Micrococcus pyogenes tenuis rarely takes the form of a bunch of grapes. 
It is occasionally found in the pus of acute abscesses. 

The micrococcus tetra genus is thought to be the bacterium chiefly respon- 
sible for the suppuration of tuberculous pulmonary lesions. 

Streptococcus Pyogenes (Fig. 16) .—This coccus, known as the chain coccus, 
grows best in air and can also grow when air is excluded. It is found in the 
healthy human body in the nasal cavities, urethra, mouth, vagina, and on the 
skin. It causes spreading inflammation and suppuration, erysipelas, pneu- 
monia, puerperal fever, pyemia, septicemia, lymphangitis, some very acute 
abscesses, and some cases of meningitis, empyema, peritonitis, pericarditis, 
osteomyelitis, and diarrhea. It varies very greatly in virulence and the in- 
tensity of its action is strongly influenced by the nature of the soil in which 
it is implanted. Not only do streptococci produce virulent toxins, but they also 
produce a non-toxic material called hemolysin, which dissolves red corpuscles. 
Woodhead tells us (Treves' "System of Surgery") that six organisms, each of 
which bears a separate name, are discussed under this designation. Three 
of these organisms he places in one group, two in another, and says the sixth 
may be a separate species. 




44 Bacteriology 

ist Group. — Streptococcus pyogenes (Fig. 16), found especially in spreading 
suppuration. Such suppurations spread because streptococci only feebly 
attract leukocytes and also prevent the coagulation of exudate. Streptococci 
are also found in very acute abscesses. Cheyne says that 16 per cent, of acute 
abscesses contain streptococci. The streptococcus pyogenes is easily killed 
by boiling, and can be destroyed by carbolic acid and corrosive sublimate. 
These organisms are normally present in the nasal passages, vagina, mouth, 
and. urethra. 

Streptococcus pyogenes malignus, an uncommon organism found in splenic 
abscess. 

Streptococcus septicus has a strong tendency to break up into diplococci. 

2d Group. — Streptococcus 0} erysipelas is found in the capillary lymph- 
spaces in erysipelas. Many bacteriologists believe it to be identical with the 
streptococcus pyogenes. These bacteria tend particularly to gather in the 
lymph-spaces. They rarely produce pus and when they do it is usually watery. 
When ordinary thick pus forms there is a mixed infection with staphylococci. 

Streptococcus of Septicemia and Pyemia. — Most observers maintain that 
it is identical with the streptococcus pyogenes and the streptococcus of ery- 
sipelas. 

3d Group.— Streptococcus articulorum, found in the false membrane of 
diphtheria (see the article by Woodhead in the "System of Surgery" by Sir 
Frederick Treves). 

Other Pyogenic Organisms. — The various forms of colon bacillus, the 
typhoid bacillus, the streptococcus intracellulosis, and the pneumococcus, are 
at times pyogenic. A common form of colon bacillus is the bacillus pyogenes 
fetidus: it is found in stinking peritoneal pus and in the pus of ischio-rectal 
abscesses. The gonococcus is also pyogenic. Blue pus is produced by the 
bacillus pyocyaneus (Ernst). 

The bacillus pyocyaneus forms chains and may produce suppuration 
itself. Usually, however, when it appears it constitutes a secondary infection 
in a suppurating area. It causes a blue or blue-green hue in pus and wound 
discharges. 

It is normally found in water and exists in the mouth, intestine, and in the 
skin. 

Other Surgical Microbes. — Streptococcus 0} erysipelas (Fehleisen's 
coccus), as stated before, is thought by many to be identical with the strepto- 
coccus pyogenes. Their difference in action is believed by Sternberg to be 
due to difference in virulence induced by external conditions and by the state 
of the tissues of the host. The coccus of erysipelas is somewhat larger than 
the ordinary form of streptococcus pyogenes. Infection takes place by a 
wound, often a very trivial wound of the skin or mucous membrane. The 
cocci multiply in the small lymph-channels. This coccus will cause puerperal 
fever in a woman in childbed when it gains access to "an absorbing sur- 
face in the genital tract" (Senn). The streptococcus may cause suppuration 
in ervsipelas, mixed infection not being necessary to induce pus-formation. 

The gonococcus, or the micrococcus gonorrhoea (the bacillus of Neisser) 
(Fig. 18), is the diplococcus which causes gonorrhea. Bumm proved the 
causative influence of the gonococcus. He reproduced the disease in a healthy 
female urethra by inoculation with the twentieth generation in descent from a 



BACTERIOLOGY 



Plate i. 






i . Staphylococcus pyogenes aureus. 

2. Staphylococcus pyogenes albus. 

3. Bacillus tuberculosis on glycerin-agar. 

^Warren's Surgical Pathology. ) 



Other Surgical Microbes 45 

pure culture. These diplococci are in pairs and each member of a pair is 
kidney-shaped (Fig. 17). Gonococci grow best in air but can grow- 
when air is excluded (facultative aerobic). Diplococci are found often 
in the secretions of apparently healthy mucous membranes, and simulate 
very closely gonococci, but genuine gonococci are not so found. Neither are 
gonococci found outside of the organism except upon articles contaminated with 
gonorrheal discharge. In male gonorrhea the gonococci are in the urethra and 
prostate; in female gonorrhea they are in the urethra, glands of Bartholin, and 
cervix uteri. These cocci may cause gonorrheal conjunctivitis, lymphangitis, 
lymphadenitis, rhinitis, otitis, proctitis, endometritis, 
salpingitis, oophoritis, cystitis, peritonitis, bursitis, the- ^ 

citis, pleuritis, malignant endocarditis, arthritis, periostitis, j*^^* 

abscess, and parotitis. In chronic urethral gonorrhea the ^* 

gonococci may at times be absent from the discharge, C£ OiD 

returning when there has been sexual or alcoholic ex- F»g- 17.— Micrococci 

cess, traumatism, or contact with an irritant secretion., s 000 "] 10 ^. highly 

magnified, schematic. 

In such a case a very few gonococci must have multi- (Lehmann and Xeu- 
plied and the majority of the bacteria must have mann.) 
quickly died so that there were never many in 
the urethra at one time, and the discharge must have been kept up by their 
irritant toxins. If a part in such a condition is irritated active multiplica- 
tion begins and the cocci reappear in the discharge. Gonococci cannot be 
cultivated upon ordinary media but grow best upon human blood or human 
blood-serum. In gonorrhea the organisms are found both within and outside 
of pus-cells and on mucous-cells (Fig. 18). The gonococci infect a surface 
covered with cylindrical epithelium much more readily than a surface 
covered with pavement epithelium. They pass into the submucous tissue, 
cause inflammation, and spread by way of the lymph paths. It seems certain 





•• 


• 


6 1 • 






• 




• ••* • 


•• 






• • • . • 




••• 


*,♦». • * 






• ••?*•« 






t«. •••• « 








• 





Fig. 18. — Gonococci from gonorrheal pus. 

that the gonococcus is pyogenic, although mixed infection with other pyogenic 
organisms may exist in this disease. Their presence inside of pus-cells means 
phagocytosis. Gonococci stain easily by methylene-blue and are readily 
decolorized by Gram's method. 

In noma streptococci are found. No specific organism has been isolated 
for traumatic spreading gangrene or hospital gangrene. 

The Bacillus of tetanus or the bacillus tctani (Xicolaier's bacillus) (Fig. 
19), is an anaerobic parasitic organism. In recent cultures at least it ceases 
to grow in the presence of oxygen and grows within the tissues of the animal 



4 6 



Bacteriology 



body. In a wound to which air has access the bacilli may lie so surrounded 
by fluid that air is excluded. Pyogenic or saprophytic bacteria may consume 
the air or the bacilli may lie in a laceration of the tissue the outlet of which 
is sealed by exudate or blood. It is a facultative saprophyte, that is, under 
certain conditions it can grow in dead organic material. It is possible to 
develop by cultivation bacilli which will live in air. 

The bacilli of tetanus are widely distributed. They are found in hay, in 
the soil of gardens, in the dust of old buildings, in street dust and dirt, and 
in the sweepings of stables. The feces of healthy horses, cattle, and men may 
contain the bacilli. Tetanus develops after a wound and the bacilli remain 
in the wound and do not enter the blood. They furnish deadly toxins which 
are absorbed. The symptoms are due to intoxication not to infection. The 
toxin of tetanus is alkaloidal not albuminoid. These bacilli stain by Gram's 




Fig. 19.— Bacillus of tetanus, with spores. 

method. Cultures are made on sugar-agar plates, the air being excluded. 
These bacilli when placed under somewhat unfavorable conditions sporulate 
with great rapidity, and the spores are seen at the ends (Fig. 19). The spores 
are far more resistant than the adult bacilli, and it is difficult to kill them in a 
wound. The drug which is most certainly fatal to tetanus bacilli is bromin. 

The Bacillus tuberculosis (Koch's bacillus) (Fig. 20). This bacillus is 
the cause of all tuberculous processes. 

It.is non-motile and requires oxygen in order to grow but may obtain this 
from the body-cells or fluids. It stains by Gram's method and by fuchsin. 
These bacilli are cultivated upon glycerin agar or solid blood-serum (Plate 1 , 
Fig- 3)- They are found in dust containing the dried sputum of victims of 
phthisis and dried discharges and secretions of tuberculous patients. This 
infected dusty air is the chief means of conveying infection (inhalation tuber- 
culosis). Infection can also be conveyed by inoculation of bacilli (inoculation 
tuberculosis) and by eating the meat and drinking the milk of tuberculous 
animals (ingestion tuberculosis). Tuberculin is discussed on page 218. 

Bacillus anthracis or the bacillus of anthrax (Fig. 21) is the cause of 



Other Surgical Microbes 47 

malignant pustule, or splenic fever. It is non-motile. Tissue containing it 
is stained by Gram's method. Cover-glass preparations are stained with a 
watery solution of an anilin dye. It will grow without oxygen but grows 
best in air. In the presence of air sporulation occurs but it does not occur 
in the infected animal. It grows upon or in gelatin or agar. Outside of the 
diseased body only the spores are found and they exist in the hides and hair 
of infected animals and in stalls and pastures in which diseased animals were 
kept. 






x . * 



Fig. 20. — Tubercle bacilli in sputum (Ziegler). 

Bacillus mallei or the bacillus 0} glanders is the cause of glanders. It 
is non-motile and grows best in air and grows with great difficulty when air 
is excluded. It grows well upon glycerin agar, and does not stain by 
Gram's method. It is never found except in the body of a diseased man or 
other animal. It is best cultivated in solid blood-serum. Under certain cir- 
cumstances some few of the bacilli contain spores. 

The Pneumococcus, called also the diplococcus pneumonia:, FrankeVs bacil- 
lus, and the streptococcus lanceolatus, is often found in the saliva of healthy in- 





Fig. zi. — Bacillus anthracis (X iooo). Fig. 22.— Bacillus of malignant edema 

(Lehmann and Neumann.) (Lehmann and Neumann). 

dividuals. It is not found outside the body. It varies greatly in virulence but 
when virulent can establish inflammation and even suppuration particularly 
of mucous and serous surfaces. It may cause croupous pneumonia, catarrhal 
pneumonia, pleuritis, meningitis, conjunctivitis, arthritis, peritonitis, periostitis, 
osteomvelitis, parotitis, salpingitis, perinephric and other abscesses, nephritis, 
tonsillitis, and septicemia. In any of these conditions it may appear in the 
blood. It grows best in bouillon cultures and in ascites glycerin agar. 



48 Bacteriology 

The Bacillus colt communis, called also the bacterium coli commune, the 
colon bacillus, or the bacillus of Escherich (Fig. 23). Under ordinary con- 
ditions this is a putrefactive bacillus inhabiting the intestinal canal and feces 
invariably contain it. It is found in the mouth, nose, and vagina, on the skin 
and under the nails. The bacillus is normally found in water, even in water 
regarded by the users as pure. It has already been stated that this ordi- 
narily harmless organism may, under certain conditions, acquire pathogenic 
power and enter the circulation. This bacterium grows best in air but it can 
also grow when air is excluded. It is not stained by Gram's method, and 
has pyogenic power. It stains with anilin, dies, and is decolorized by iodin solu- 
tion. There are numerous forms of colon bacilli, and some of them are motile, 
some are amotile. This bacillus may be responsible for appendicitis, peritonitis, 
inflammation of the genito-urinary tract, pneumonia, inflammation of the 
intestine, leptomeningitis, perirenal abscess, cholangitis, cholecystitis, myel- 
itis, puerperal fever, wound infection, and septicemia. It is the cause of 
many abscesses about the intestine, and is responsible for many ischiorectal 
abscesses. From the pus of an appendiceal abscess we may perhaps obtain 
a pure culture of Escherich's bacillus, but usually find also streptococci, 
staphylococci, or pneumococci. 

The Spirochazta Pallida. — A bacterial cause of syphilis has long been 
sought for. Lustgarten thought he had found it in a bacillus resembling the 
tubercle bacillus, but this view has not been proved. Schaudinn and Hoff- 
mann have described an organism constantly present in the initial lesion of 
syphilis and in secondary lesions and which they call the spirochaeta pallida 
("Arbeiten aus dem Kaiserlichen gesundheitsamte, " Berlin, April 10th, Heft 
2). These organisms are found in great numbers in the juice of syphilitic 
glands, in condylomata, and in chancres. They are motile, are without 
flagella, curve from 3 to 12 times, and are stained with difficulty. Rosen- 
berger considers it to be a protozoon and to belong with the animal para- 
sites. The spirochaeta was originally discovered by Bordet and Geugm in 
1903. These observers found them in chancres but thought their presence 
was inconstant, Schaudinn and Hoffmann show that it is constant. Many 
observers believe it is the cause of syphilis. Rosenberger says " that it plays 
some part in the etiology of syphilis seems plausible, as it has not been 
encountered except by one or two observers in any other lesion than syph- 
ilis" ("Am. Jour. Med. Sciences, " Jan., 1906). 

The Bacillus osdematis maligni, the bacillus 0} malignant edema or the 
vibrione septique of Pasteur (Fig. 22). This bacillus is found especially in stag- 
nant water and certain varieties of soil and exists in putrefying material. It is 
sometimes motile but is often amotile and multiplies by spore formation. It 
is anaerobic and in its growth produces bubbles of gas. In the disease known 
as malignant edema there is usually a mixed infection with the bacilli of 
malignant edema and saprophytic organisms, and the latter also form con- 
siderable quantities of gas in the tissues. The bacilli of malignant edema 
may cause either spreading bloody edema containing gas bubbles or spreading 
emphysematous gangrene. The bacilli enter the blood and produce septice- 
mia. The bacillus is grown in the interior of a stab in gelatin agar-agar or 
solid blood-serum when the mouth of the stab has been sealed up. 

The Bacillus Aerogenes Capsulatus 0} Welch. — This bacillus is found some- 



Putrefactive Bacteria 49 

times in abscesses containing gas. It is causative of some cases of gangrenous 
cellulitis which is a spreading gangrene with gas formation. 

This bacillus has a capsule and very seldom forms spores. It stains by 
Gram's method and grows well upon blood-serum. 

As pointed out by Lehmann and Neumann there are occasionally encountered 
"gaseous phlegmons and similar diseases of internal organs, in which are 
found the bacterium coli alone or usually in combination with other varieties, 
but without any anaerobes being present (" Atlas and Principles of Bacte- 
riology, " Vol. II, edited by Geo. H. Weaver). 

The Bacterium typhi, the typhoid bacillus, or Eberth's bacillus, is some- 
times found in water or soil contaminated by typhoid fecal matter. It never 
exists in the healthy human body. It causes typhoid fever and in this dis- 
ease can be obtained and cultivated particularly from the spleen and lymphatic 
glands and frequently from the blood. It has been found in urine, kidney, 
bone marrow, and bile. It is difficult to cultivate typhoid bacilli from feces 
because of the presence of multitudes of other bacteria. The bacillus of typhoid 



'k 



r 






Yf. 






i 



)f J ' « M -' X 

Fig. 23. — Bacillus coli communis. 

is motile, does not stain by Gram's method, and grows best in air but can grow 
when air is excluded. It grows upon all the ordinary nutrient media. This 
bacillus is particularly apt to be confounded with the colon bacillus, and it is 
even possible that the former develops from the latter. Besides typhoid fever 
the typhoid bacillus may cause peritonitis, chronic osteomyelitis, gangrene, 
cholecystitis, thrombosis, embolism, synovitis, and arthritis. This bacillus, 
under certain conditions, is pyogenic. Typhoid bacilli are agglutinated and 
lose motion by contact with a 1 to 50 dilution of the blood-serum of a patient 
with typhoid fever or convalescent from typhoid fever (the Widal reaction). 

Putrefactive Bacteria. — By putrefaction we mean the decomposition 
of albuminous matter with the production of materials possessed of a foul odor. 
The bacilli of putrefaction act upon dead tissue exposed to air and are most 
active when the supply of air is somewhat limited. The surgeon encounters 
these bacteria in areas of necrosis or in tissues previously destroyed by other 
microbes. In the latter case they cause a mixed infection. An instance of such 
a mixed infection is putrid pus. Some of the products of putrefactive bac- 

4 



50 Asepsis and Antisepsis 

teria are highly poisonous (ptomai'ns). Absorption of a small amount of 
putrid toxin causes surgical fever and absorption of a large amount causes 
putrid intoxication. 

The chief putrefactive alkaloids are: The colon bacillus (when under 
normal conditions); the bacillus of malignant edema; the proteus vulgaris; 
the proteus mirabilis; the three forms of the bacillus saprogenes; and the 
proteus Zenkeri. 

We may mention, in conclusion, as of occasional surgical importance, the 
bacillus of influenza, bacillus of diphtheria, bacillus of bubonic plague, 
bacillus of leprosy, bacillus of rhinoscleroma, bacillus of fetid ozena, bacillus 
of hemorrhagic septicemia, and bacillus lactis aerogenes, which is an un- 
usual cause of peritonitis. 

The ray- jungus is considered on page 272. 

Infections with Protozoa. — Protozoa is the name given to the lowest 
forms of animal life. This group of organisms shows transitions from forms 
certainly animal toward forms certainly vegetable. The protozoa are minute 
unicellular organisms. The cell has a definite nucleus and is composed of 
protoplasm and a more or less dense cell-wall. Many species have organs 
of locomotion (cilia or flagella). Protozoa are known to cause malaria (the 
Plasmodium malariae) and tropical dysentery (the entameba histolytica). 
Some observers maintain that they cause cancer, and it is thought probable 
that they may produce smallpox, yellow fever, scarlatina, and spotted fever. 



II. ASEPSIS AND ANTISEPSIS. 

The effort in all operations is to secure and maintain scrupulous surgical 
cleanliness. What is known as the antiseptic method we owe to the splendid 
labors of Lord Lister, and the aseptic method is but a natural evolution of 
the antiseptic method. It is true that Agostino Bassi, over half a century ago, 
convinced that various maladies were due to parasites, treated wounds with 
a solution of corrosive sublimate. It is also true that Semmelweis in 1847 
demonstrated the infectiousness of puerperal fever and the method of prevent- 
ing it; that Jules Lemaire in 1863 published a treatise on carbolic acid and 
advocated the use of this drug in the treatment of wounds in order to destroy 
living germs, and that Bottini in 1866 employed carbolic acid in the treatment 
of putrid and suppurating wounds because he believed germs to be responsible 
for such conditions (Monti on "Modern Pathology"). In spite of the above 
facts, Lister is the real father of asepsis and taught all nations how to prevent 
infection. Monti says: "But Lister, with that practical spirit which forms 
one of the best characteristics of English genius, from the scientific studies 
of Pasteur, deduced the general laws of antisepsis and the rules for their 
methodical application to practical surgery. " Lister called the attention of 
the profession to a new method of treating wounds, compound fractures, 
and abscesses in 1867* The processes first employed were extremely com- 
plicated, but have been made in the last few years simple and easy of per- 
formance. Lister believed the chief danger to be from air. It is now believed 
that the chief danger is from actual contact of hands, instruments, dressings, 

* The Lancet. 



Asepsis and Antisepsis 51 

or foreign bodies with a wound. Air carries but few micro-organisms unless 
it is filled with dust. Infection through air is most apt to occur if the air is 
dusty, and is more common after an aseptic than an antiseptic operation. 

Of course, some bacteria from the air must settle in every wound, but 
the majority of air fungi are harmless. Comparatively few reach the wound 
unless the air is dusty, and these few the tissues are usually able to destroy. 
Schimmelbusch made experiments in v. Bergmann's clinic when the stu- 
dents were present. He found that ''the number of bacteria which settle 
upon the surface of a wound a square decimeter in extent, in the course of half 
an hour, is about 60 or 70, " and thousands are usually required to produce 
infection. 

There is no danger of the breath alone producing infection. Air which 
comes from the lungs is germ-free, and even a large class will not infect the 
air by breathing, but will rather help free it from bacteria, for the lungs are 
filters for air laden with micro-organisms. 

In performing any surgical operation cutting is better than tearing by 
blunt dissection. The former method makes an incised wound, the latter a 
lacerated wound. In an incised wound there is a minimum amount of dam- 
age and rapid repair. In a lacerated wound some necrosis occurs and there 
is great lowering of tissue resistance, hence a lacerated wound is much more 
apt to become infected than is an incised wound. 

Surgical cleanliness may be obtained by either the aseptic or the antiseptic 
method. In the aseptic method heat, chemical germicides, or both are used 
to cleanse the instruments, the field of operation, and the hands of the surgeon 
and his assistants, the surface being freed from the chemical germicide by 
washing with boiled water or with saline solution. After the incision has 
been made no chemical germicide is used, the wound being simply sponged 
with gauze sterilized by heat; if irrigation is necessary, boiled water or normal 
salt solution is used, and the wound is dressed with gauze which has been 
rendered sterile by heat. The effort of the surgeon is simply to prevent the 
entrance of micro-organisms into the tissues. Some micro-organisms must 
enter, but the number will be so small that healthy tissues wil destroy them. 
The aseptic method should be used only in non-infected areas. If chemical 
germicides are not used, there will be a minimum amount of irritation, few 
cells will be destroyed, the amount of wound-fluid will be small, the surgeon 
can often dispense with drainage, and repair will be rapid. If a wound is 
to be closed without drainage, every point of bleeding must be ligated. Many 
wounds are closed by interrupted through-and-through sutures. Some wounds 
are closed in layers. If a wound is closed in layers, muscle being against muscle, 
fascia against fascia, etc., the skin may be closed by interrupted sutures or by 
Halsted's subcuticular stitch. If this stitch is employed, the skin staphylo- 
coccus does not obtain access to stitch-holes, and stitch-abscesses are not apt 
to arise. This suture may consist of catgut, silk, or, preferably, silver wire, 
this latter agent being capable of certain sterilization by heat and exercising 
a powerful inhibitor}- action on micro-organisms. If a wound is closed with- 
out drainage, firm compression is applied over the wound to obliterate any 
cavity which may exist. Such a cavity is called a dead-space. If a dead- 
space is allowed to remain wound-fluid will gather, tissue resistance will be 
lowered, and the wound-fluid, the tissue, or both, may become infected. 



52 Asepsis and Antisepsis 

Drainage must be used if the wound is very large, if its shape or 
structure prevents the obliteration of the cavity by pressure, if there is 
any doubt as to the perfect cleanliness of the part, if the patient is very fat, 
for in such individuals fat necrosis predisposes to sepsis and to fat embolism, 
and if the skin is so thin that we fear pressure will produce sloughing ("A 
Manual of Surgical Treatment," by Cheyne and Burghard). In some 
regions of the body wounds are sealed with collodion or iodoform-collo- 
dion. If irrigation is not practiced and the wound is dressed with dry sterile 
gauze, the procedure is said to be by the "dry" aseptic method. In the 
antiseptic method the same preparations are made for the operation as in the 
aseptic method, but during the operation sponges impregnated with a chemi- 
cal germicide are used, and the wound is dressed with gauze containing cor- 
rosive sublimate or some other chemical germicide. If the wound is not 
flushed with a chemical germicide, and is dressed with dry antiseptic gauze, 
the operation is said to be by the "dry" antiseptic method. The antiseptic 
method is preferred in infected areas. Dry dressings are usually preferable 
to moist dressings in treating aseptic wounds, because they are more absorbent 
and do not act as poultices, and dry dressings may be used, even when the 
wound has been flushed. Some surgeons question the value of antiseptic 
irrigation in a septic wound, but I believe it removes many bacteria and 
much poisonous matter and also antidotes toxic material. In suppurating 
areas it is often best to use moist dressings in the form of antiseptic fomen- 
tations. Year by year the aseptic method becomes more popular. Surgeons 
have learned that the most important factor in asepsis is mechanical cleans- 
ing by means of soap and water. The chemical germicide plays a secondary 
rather than a vital part. By mechanical cleansing great numbers of micro- 
organisms are removed along with dirt, grease, and epithelium. Many 
bacteria remain, but vast hordes are washed away, and the danger of infec- 
tion is greatly lessened by thus diminishing the number of bacteria. If a 
chemical germicide is used without preliminary mechanical cleansing, it is 
useless, because it cannot destroy bacteria in the epithelium and in masses 
of oily matter. After mechanical cleansing the germicide is active in destroy- 
ing the comparatively few bacteria which are naked on the surface. In many 
regions a strong chemical germicide must not be used (in the abdomen, in 
the brain, in joints, in the pleural sac, and in the bladder), and in other 
regions (mucous surfaces and fatty tissue) it is productive of harm rather 
than good. 

Preparation for an Operation. — If the operation is to be performed 
in a hospital there is, of course, an operating room always ready. If it is to 
be done in a private house, much careful preparation is desirable. A room 
in which an operation is to be performed should be well lighted and well 
ventilated. The northern light is the best. It is advantageous to 
have an open grate in the room, for then a wood fire can be quickly 
made to take a chill off the air and ventilation is improved. The 
morning before the operation the furniture should be removed, the carpet 
taken up, and the curtains and hangings taken down. If the ceiling 
and walls are papered, they must be thoroughly brushed. If they are 
painted, they must be washed with soap and water. Dust is thus removed, 
and the danger of dust falling into the wound is averted. The floor is scrubbed 



Preparation for an Operation 



53 



with soap and water. The windows should be opened for many hours to 
thoroughly dry and freshen the room. On the morning of the operation the 
windows are closed and newspapers are tacked up so as to cover the lower 
half of each window. Plenty of light is admitted and the curiosity of neigh- 
bors across the street cannot be satisfied. The patient's bed is brought into the 
room and placed in a position where there will be plenty of light for future dress- 
ings, and where the surgeon will have access from either side. In order that 
there may be access from each side the bed must not be in a corner or against 
the wall. Never use a big broad bed; use a narrow bed. Never have a 
feather bed, but insist on Treves's advice being followed, and employ a 
metal bed with a wire netting and hair mattress. 

A piece of carpet or rug is spread upon a portion of the floor and the table 
is set upon it. The table should be so placed that there will be a good light 
on the field of operation. There are several tables which are very satisfac- 
tory. The best for a private house operation is Lilienthal's (Figs. 30 and 
31). This table can be folded into a small 
compass, can be carried in a case with a 
handle, and is comparatively light and 
easily transportable. It can be rapidly 





Plain double wash-stand. 



Fig. 25. — Revolving wash-stand. 



set up, is firm, and it enables the surgeon to obtain the Trendelenburg posi- 
tion at any moment. A kitchen table does very well. If a kitchen table is 
used and the abdomen is to be opened a frame should be at hand which, 
when slipped under the patient, enables the surgeon to obtain the Trendelen- 
burg position. Dr. Joseph Price uses, instead of a table, two trestles and a 
board like an ironing board. In hospital work 1 use Boldt's table (Figs. 28 
and 29). On the table or board is placed a folded comfortable or several 
folded blankets and Kelly's pad to catch fluids is laid upon the blankets and 
is so placed that fluid used in irrigation will flow into it and will be conducted 
by it to a suitable receptacle. 

Around the operating table at proper distances are arranged a table for 
instruments, a table for dressings, a table for sponges and a basin of bichlorid, 
and a table for soap and a basin of water. Ordinary wooden tables may be 
used if they are covered with towels wet in corrosive sublimate solution. In 
a hospital special tables are used. They are of iron with glass tops. 
Ordinary basins may be used but enameled or glass basins in stands (Figs. 



54 



Asepsis and Antisepsis 



24 and 25) are the most satisfactory. A couple of buckets should be placed 
on the floor near at hand. Enameled buckets are the best ones to use. The 
nurses and assistants should have ready the ether cone, wrapped in a clean 
towel, sterile sheets, sterile gowns, sterile towels, sterile gauze for sponges and 
dressings, trays for instruments (Figs. 26 and 27), iodoform gauze, catgut, 
silk, silkworm-gut, hot normal salt solution, etc., according to the nature of the 





Fig. 26. — Porcelain surgical tray. 



Fig. 27. — Glass surgical tray. 



operation. The surgeon should pick out the instruments required. The 
anesthetizer should lay out a mouth-gag, tongue-forceps, a hypodermatic syringe 
in working order, ether or chloroform, brandy, tablets of strychnin, and also 
of atropin. 

If the operation is to be performed in a hospital, it is desirable to have 
the patient admitted two or three days before. He adjusts himself to his 




Fig. 28. — Boldt's operating table. 

surroundings, becomes accustomed to diminished activity, forms an acquaint- 
ance with his nurses and physicians, and, as a rule, becomes less nervous 
and more calmly confident of the result. The patient is prepared the day 
before the operation, except in an emergency case. 

When the time for the operation arrives, the surgeon and his assistants 
remove their coats, roll up their sleeves, and, after sterilizing the hands and 



Danger from the Hands 



55 



forearms, envelop their bodies in aseptic or antiseptic sheets or gowns, to 
protect the patient and themselves. It is a good plan for the surgeon and 
his assistants to wear sterile muslin caps. The caps prevent hair, dandruff, 
and sweat falling into the wound. Mikulicz and some other operators wear 
over the mouth and nose a respirator or piece of gauze in order to prevent 
saliva or mucus being projected into the wound while the surgeon talks. 

Danger from the Hands. — It is a difficult or impossible matter to abso- 
lutely sterilize the hands, but it is fortunate, as Mikulicz and Fliigge say, that 
most of the bacteria of the skin are harmless. The staphylococcus epidermidis 
albus, however, is constantly present in the epidermis. The hands of some 
persons are more easily sterilized than those of others. For instance, a hairy, 
creased hand is more difficult to sterilize than a smooth and almost hair- 




Fig. 29. — Boldt's operating table. 



less one; a hand grossly neglected, than one reasonably clean. Germs abound 
in the epidermis, in the fissures and creases, under and around the nails, on 
hairs, and in ducts of glands. The surface of the hands may be thoroughly 
sterile at the beginning of an operation and become infected later, because 
germs in gland ducts are forced to the surface. Hence, in a prolonged opera- 
tion, the surgeon should stop from time to time and wash his hands, first 
in alcohol and then in corrosive sublimate solution (Leonard Freeman). 

In view of the difficulty of cleansing the hands, every student must be 
taught how to do it, and he must become impressed with the fact that the 
surgical hand is to be regarded as reaching to the elbow. The more hands 
used in an operation, the greater is the danger of infection of the wound. 
The surgeon uses retractors and forceps whenever possible, but his fingers 



56 



Asepsis and Antisepsis 



must enter the wound. The fingers of no other person should enter unless 
absolutely necessary. The basis of all plans of sterilization and the most 
important part of any plan is mechanical cleansing by scrubbing with soap 




Fig. 30. — Lilienthal's portable operating table. 




Fig. 31. — Lilienthal's portable operating table, folded. 



and water. By this means a quantity of loose epidermis is removed and with 
it great numbers of bacteria. 

Mechanical Cleansing of the Hands and Forearms. — The hands and 



Sterilization of Hands and Forearms 



57 



forearms may be sterilized in several ways. Any method is preceded by 
mechanical cleansing, which is carried out as follows: Scrub for five minutes 
with soap and hot sterile water, giving special attention to the nails and creases 
in the skin. The water should be as hot as can be borne with comfort as 
hot water stimulates the sweat glands and the flow of sweat washes out the 
ducts and during the operation the secretion will be slight. The brush is 
rubbed in the long axis of the extremity and also transversely. The creases 
on the back of the hands and fingers will be partially opened by flexing 
the fingers, and transverse scrubbing will clean the furrows. The furrows 
on the palmar surface will be opened by extending the fingers, and will be 
best cleaned by transverse scrubbing (George Ben Johnston). An excellent 
soap is the ethereal soap of Johnston, which is a solution of castile soap in ether. 
Green, or castile soap can be used. Many surgeons use synol soap. It is 
an admirable cleanser but there is no particular advantage in using a soap 
containing a germicide, as such a soap is practically without germicidal 
power. The brush employed should be kept in a i : iooo solution of cor- 
rosive sublimate or should have been recently sterilized with steam and kept 
in a sterile glass box (Fig. 32). The nails are cut short, are cleansed with a 
knife or, better, with an orange-wood 
stick, which does not scratch them, 
and the hands are again scrubbed. 
Very prolonged or very rough scrub- 
bing, especially with harsh agents like 
marble dust or sand, is actually harm- 
ful as it tends to crack the hands and 
make them rough and it extensively 
loosens epidermis which may drop into 
the wound. Epidermis may contain 
bacteria within it and may infect the 
wound. 

Sterilization of the Hands and Forearms. — After mechanical cleans- 
ing a germicide is employed to render the parts sterile. Whatever method 
is adopted it is desirable that it shall not unduly irritate the skin. An occa- 
sional operator may use without injury tolerably strong chemicals, but the 
busy hospital surgeon, who operates perhaps several times or many times a 
day, cannot use them. Any method which inflames, cracks or roughens the 
skin makes future sterilization difficult or impossible, hence such a method is 
undesirable. Four methods are described here: 

Fiirbringer's Method: After washing off the soap in sterile water the hands 
are dipped in 95 per cent, alcohol and held there for two or three minutes while 
the forearms, hands, fingers, and nails are being rubbed with alcohol. Alcohol 
removes the soap which has entered into follicles and creases, removes desqua- 
mated epithelium, enters under and about the nails, and favors the diffusion 
of the corrosive sublimate under the nails and into the follicles, when the hands 
are placed later in the mercurial solution. Alcohol also hardens epithelium 
and keeps it from desquamating into the wound. After using the alcohol 
the hands are then dipped in a hot solution of corrosive sublimate (1 : 1000 \ 
and with the forearms are scrubbed for at least a minute, the nails receiving 
especial care. 




Fig. 32 — Glass brush-box with cover. 



58 Asepsis and Antisepsis 

The Welch-Kelly Method: After the hands and forearms have been cleansed 
mechanically and have been rinsed in sterile water they are immersed for 
two minutes in a warm solution of permanganate of potassium (a saturated 
solution in distilled water). This solution causes the cutaneous surface to 
assume a very dark brown color. The hands and forearms are then immersed 
in a warm saturated solution of oxalic acid and are held there until decolor- 
ized. They are then well washed in sterile water, are next immersed for 
two minutes in a 1 : 500 solution of corrosive sublimate, and finally are rinsed 
in sterile water and dried on a sterile towel. The solutions for use in the above 
method should be contained in jars of the shape of a druggist's percolator 
so that both the hands and forearms can be immersed at the same time. In 
this method the permanganate of potash is merely an oxidizer and the 
oxalic acid is the active germicide. The skin of some persons tolerates the 
plan very well, others, among whom is the author, find the oxalic acid deci- 
dedly irritant when used several times in a day. 

The Weir-Stimson Method: This method was suggested by Mr. Rausch- 
enberg, the pharmacist of the New York Hospital, and it was practically 
applied by Doctors Weir and Stimson. The process is as follows: The hands 
should be cleansed mechanically as previously directed or, as Weir prefers, 
by scrubbing with a brush and green soap and in running hot water and clean- 
ing under the nails with a piece of soft wood. Place about a tablespoonful 
of chlorinated lime in the palm of the hand, place upon the lime a piece of 
crystalline carbonate of soda (washing soda) one inch square and half an 
inch thick, add a little water, and rub the creamy mixture over the arms and 
hands until the rough granules of sodium carbonate are no longer felt. This 
requires from three to five minutes. At first there is a sensation of heat usually 
followed by a sensation of coolness. Place the paste under and around the 
nails by means of a bit of sterile orange-wood. Wash the arms and hands 
in hot sterile water.* Remove the odor of chlorin by washing the hands and 
arms in sterile ammonia water of a strength of from ^ per cent, to 1 per cent. 
(McBurney, Collins, and Oastler, in "International Text-Book of Surgery"). 
The combination of carbonate of sodium and chlorinated lime is said to set free 
nascent chlorin, a most efficient germicide. This method has proved extremely 
efficient in the clinic of the Jefferson Medical College Hospital, although 
when employed several times a day it may prove decidedly irritant. It is 
important that crystalline washing-soda be employed. If the bicarbonate 
is used, nascent chlorin will not be produced, but hydrochloric acid gas 
will be formed, and the latter gas irritates the skin and is not a satisfactory 
germicide. 

The Sublimate- Alcohol Method: This is the method I personally prefer. 
It is as follows : Cleanse the hands with soap and water as previously directed. 
Use 95 per cent, alcohol as in Fiirbringer's method (page 57). Dip the hands 
in 70 per cent, alcohol containing 1 part to 1000 of corrosive sublimate, and 
rub the hands, forearms, and nails with a piece of sterile gauze wet with this 
fluid for three minutes. Rinse these parts in the fluid and then rinse in 
sterile water. 

The Use of Gloves. — Some surgeons are so impressed with the impos- 
sibility of sterilizing the hands that they wear gloves in operations. Hunter 
* Medical Record, April 3, 1897. 



The Use of Gloves 



59 



Robb is said to have suggested the use of gloves in 1894, but Halsted began 
to use rubber gloves in 1889. Mikulicz used white cotton gloves. Lockett 
has proved that cotton and silk are not impervious to micro-organisms, but 
that rubber is. The thin, seamless rubber gloves which are now made are 
very satisfactory. They are sterilized by boiling, are then dried, and are 
wrapped in a sterile towel. In order to insert the hand in them the hand should 
be dried, the interior of the glove should be dusted with sterile starch or talc 
powder, and then the nurse should fold forward the wrist part and hold the 
glove open while the surgeon inserts his fingers into the proper compartments 
and pushes the hand in. The custom of filling the glove with sterile fluid and 
then inserting the hand is troublesome and objectionable, because the fingers 
soon become sodden like those of a washwoman, the sense of touch is im- 
paired, considerable discomfort is occasioned, and the skin is apt to crack open. 




F'g- 33- — Showing rubber glove applied. 



If, during an operation, a glove becomes infected, a clean one can be 
substituted for it. Gloves somewhat impair the sense of touch, but a surgeon 
soon learns to work with them. If they are to be used, the hands should be 
sterilized just as carefully as when they are not to be used, because, during 
the operation, the gloves may tear or be punctured by a needle. That it is 
absolutely necessary to wear gloves in all cases has not been proved. Their 
use does contribute to success in brain operations, abdominal operations, 
and joint operations. They are of great value in military surgery for the 
military surgeons may not have time to prepare his hands and sterile gloves 
can be always kept ready prepared. 

When a surgeon is obliged to place his fingers in an area of virulent infec- 
tion he may be poisoned. Gloves will save him from this danger. Again, 
a surgeon should try to avoid bringing his hands unnecessarily in contact 
with putrid or purulent matter. Though it may not poison him, it grossly 
infects the surface, renders subsequent cleansing difficult, and endangers 



6o 



Asepsis and Antisepsis 




Fig. 34.— Half-long rubber glove. 



other patients. Gloves will prevent this danger. A surgeon should wear 
gloves if he is making an examination or performing an operation which is 
sure to infect the bare hands, and he should wear gloves in an operation if in a 
previous operation his hands were infected.* A surgeon whose hands are 
very hairy or sweat much will contribute to the patient's safety by wearing gloves. 
Gloves should be worn if the surgeon has a wound or sore upon his hand 
or chapped hands. When using gloves in a prolonged operation dip the 
covered hands now and then in corrosive sublimate solution, because the 
glove may have been punctured or dust may have settled upon it from the air. 
Gloves make the hands sweat and if one should be punctured considerable 
sweat may emerge from the puncture and enter the wound and sweat often 

contains bacteria. The entry of any consider- 
able amount of sweat is more dangerous to the 
patient than are well cleaned naked hands, 
hence gloves may actually favor the infection 
they are meant to prevent. When they are 
used the surgeon must take scrupulous care 
not to puncture them with a needle, clip them 
with forceps, or tear them with a ligature or suture. 
The closer they fit the less the danger of puncture and one should know 
accurately what size he requires to fit closely and smoothly without being so 
tight as to make the fingers numb. 

Preparation of Gloves. — Wash with soap and water containing a little ammo- 
nia, rinse in sterile water, boil for thirty minutes in a 1 per cent, solution of car- 
bonate of soda. Dry the glove and wrap in a dry sterile towel and keep until 
it is needed. A pair of gloves should stand about 20 boilings. The surgeon 
should carry a number of pairs of prepared gloves in his bag, for the use of 
himself and assistants in private house operations. 

Instruments are disinfected by subjecting them to the action of steam 
in a special sterilizer, or better by boiling them for fifteen minutes in a 1 per 

cent, solution of carbonate of sodium. 

a 

They are wrapped into a bundle by 
means of a towel or piece of gauze and 
are dropped into the solution. The 
blades of knives should first be wrapped 
in cotton to prevent scratching and 



- ; 





Fig- 35-— ". Schimmelbusch's gas-heated apparatus for sterilizing instruments; b, wire basket. 

dulling. After boiling, the instruments should be rinsed in hot sterile water 

*A review of the literature of disinfection of the hands, by Martin B. Tinker and A. 
B. Craig, will be found in the Phila. Med. Journal, Feb. 15, 1902. See also Edgar R. 
McGuire, in "The Best Method of Hand Sterilization," in American Medicine, Feb. 28, 
1903; Robert T. Morris, on "Rubber Gloves in Surgery," New York Medical Journal, 
Nov. 22, 1902; and "Sterilization of the Hands," by Charles Leedham-Green, in the 
Birmingham Med. Review, April 1904. 




Preparation of the Patient 61 

or in a 5 per cent, solution of carbolic acid and be kept until needed in a pan 
of sterile water. The carbonate of sodium prevents rusting. In a clinic 
the boiling is carried out in a Schimmelbusch sterilizer (Fig. 35). In a 
private house it can be done in a sterilizer such as that shown in Fig. 36, or 
in a pan, a kettle, or a wash-boiler. A sterilizer with a tray is better than 
an ordinary pan or kettle, because, when the latter is used, the metal instru- 
ments lie in the bottom of the vessel, where the heat is very great, and the 
temper may be impaired. 
Boiling unfortunately destroys 
to some extent the keenness of 
cutting instruments, the ebul- 
lition throwing them about. 
Hence the knives should be 
wrapped in cotton to preserve 
the edges. After sterilization Fig 36 ._p ortab , e sterilizer. 

the instruments are placed in 

trays containing boiled water. After the completion of the operation the 
instruments should be scrubbed with soap and water, boiled in soda solution, 
dried, and placed in a closet with glass shelves so they will not gather 
dust. Instruments can be partially disinfected by keeping them for thirty 
minutes in a 5 per cent, solution of carbolic acid or better, in a 2 per cent, solu- 
tion of formalin. Instruments with handles of wood must not be boiled. If 
such instruments are used, they can be disinfected by the use of carbolic acid 
or formalin, but they should not be used. Metal instruments, whenever pos- 
sible, should consist of one smooth piece. Grooves and letters are objec- 
tionable, as dirt gathers in such depressions. Ivory handles cannot be boiled. 
Preparation of the Patient. — Whenever possible give the patient some 
days' rest in bed before a severe operation. During this preliminary rest 
study the disease, and study the individual in order to learn his tendencies, 
peculiarities, etc. The condition of the lungs, the heart, the blood, and the 
kidneys should be accurately determined. The amount of urine passed in 
twenty-four hours should be ascertained, and the percentage of urea should 
be estimated from a sample of the twenty-four hours' urine. The urine is 
carefully examined for sugar, albumin, casts, acetone, diacetic acid, etc. By 
the above examinations we may be able to anticipate and provide against cer- 
tain calamities: We maybe led to postpone or abandon an operation, and 
we will be made able to intelligently select the proper anesthetic. The an- 
esthetizer should during this preliminary period examine the heart and pulse 
so as to know what these characters are naturally when the patient is free from 
excitement. Without this preliminary knowledge he cannot accurately appre- 
ciate and intelligently interpret some changes induced by the anesthetic. 
Constipation must be amended by mild laxatives or enemas, and all fermented 
matter should be removed from the alimentary canal. Constipation increases 
the danger of wound infection and greatly impairs the comfort of the patient. 
As previously shown the putrefactive bacteria in the intestinal canal, which 
are usually harmless and are what Adami calls "potential parasites," may 
escape. The retention of fermented matter causes catarrhal inflammation and 
bacteria escape more easily. If they escape they may lead to damage in the 
wound and even if wound infection from within does not occur, constipation 



62 Asepsis and Antisepsis 

lessens vital resistance and increases the liability to wound infection from with- 
out. Purgatives must not be violent as anything which greatly depresses a per- 
son lessens vital resistance and powerful purgatives are powerful depressants. 
The diet should be bland and nutritious but not bulky. The night before the 
operation give a saline cathartic, and the morning of the operation employ 
an enema. Not only do we empty the bowel to lessen the liability to wound 
infection but we wish the rectum empty at the time of operation for another 
reason. It is desirable that the rectum be empty, because in shock the absorb- 
ing power of the stomach is greatly diminished or is even abolished for the 
time, and we may wish to utilize the absorbing power of the rectum and give 
stimulants by enema. When a patient is under the influence of an anesthetic, 
or when he is profoundly shocked, of course no attempt is made to give 
stimulants by the mouth. Whenever possible, give a general warm bath the 
day before the operation. The evening before the operation shave the region 
if hairy, scrub the entire field of operation, as well as the adjoining regions, 
with ethereal soap and water; wash with ether or alcohol; scrub with hot 
corrosive sublimate solution (i : iooo); apply a layer of moist corrosive sub- 
limate gauze, and place over this dry antiseptic gauze, a rubber dam, and a 
bandage. Many surgeons apply a poultice of green soap for many hours 
before applying a chemical germicide, in order to separate masses of epithe- 
lium and with them many germs. This method is particularly useful in 
cleansing the scalp. On removing the dressings to perform the operation, 
scrub the part with soap and water, wash it with sterile water and then with 
alcohol, surround the field of operation with dry sterile sheets and towels 
and scrub the exposed area with a hot solution of corrosive sublimate (i :iooo). 
Murphy prevents infection from the cutaneous surface by spreading a spe- 
cially prepared rubber solution over the sterilized operation area. The solu- 
tion is sterile and sticks to the skin and is applied after the skin has been 
washed first with ether and then with alcohol. The rubber is dissolved in 
acetone and is painted on the skin. The incisions are made through the arti- 
ficial skin of rubber and the rubber is removed when the surgeon is ready to 
introduce the sutures. Thus infection of the wound with contaminated secre- 
tion of the skin glands is prevented, for, as Murphy says, this elastic covering 
is "in reality a non-secreting, sterile, artificial derma, for the period of opera- 
tion" ("General Surgery, " edited by John B. Murphy, vol. ii, 1905). The 
patient must be carefully protected from cold by wrapping him in blankets 
and often by having him wear specially prepared drawers with feet. After 
the completion of an operation and the application of the dressings the patient 
is returned to his room or the ward, care being taken to protect him from 
cold or draughts. In emergency cases disinfection can only be practiced just 
previous to the operation. Disinfection in such cases can be thoroughlv 
effected by shaving, scrubbing with soap and water, washing with alcohol, and 
then using chlorinated lime and washing soda. 

Disinfection of Mucous Membranes. — It is impossible to thoroughly 
disinfect mucous membranes. We must not scrub forcibly, and we must not 
use powerful antiseptics because they are irritant and also because they may 
be absorbed. The best that can be done in the vagina is to rub lightly, 
when possible, with a bit of moist absorbent cotton and irrigate with a solution 
of boric acid or with normal salt solution. Another method is to sponge the 



Ligatures and Sutures 63 

vagina with creolin and Johnston's ethereal soap (1 and 16) and irrigate with 
hot saline fluid or boric acid. 

The rectum is prepared by washing out all retained feces by the use of 
copious high injections and by irrigating with salt solution or boric acid. 

The mouth is prepared by having snags of teeth and tartar removed and 
decayed teeth removed or plugged. For several days before the operation 
scrub the teeth twice a day with a soft brush and castile soap; and every three 
hours, when the patient is awake, rinse the mouth with peroxid of hydrogen 
and spray the nares and nasopharynx with boric acid solution. 

The urethra is prepared by the administration for several days of salol or 
urotropin and by frequent irrigation of the urethra and bladder with boric 
acid solution or normal salt solution or a solution of permanganate of potash 
(1 : 6000). 

Preparation of a Patient for an Operation upon the Stomach (see page 918). 

Irrigation is often practiced in septic wounds, but is not required in 
aseptic wounds. In a septic wound gentle irrigation with a germicide is 
advisable. It removes bacteria and toxins and antidotes retained toxins. 
Irrigation must never be forcible for fear it may disseminate infection. Among 
irrigating fluids we may mention corrosive sublimate, carbolic acid, peroxid 
of hydrogen, boric acid solution, and normal salt solution. Hot normal 
salt solution is the best agent with which to irrigate the peritoneal cavity, the 
pleural sac, the interior of joints, and the surface of the brain. This solution 
contains 0.7 per cent, of sodium chloric! . 

Many surgeons employ Landerer's dry method in operating aseptically. 
No fluid is applied to the wound. As the wound is enlarged gauze sponges 
are packed in to arrest hemorrhage. On the completion of the operation the 
sponges are removed, bleeding points are ligated, and the wound is often 
closed without drainage. 

Ligatures and Sutures. — In using sutures always remember that they 
must be tied firmly, but never tightly. A tight suture will cut when the 
wound swells and will thus fail of its purpose; further, it produces an area 
of tissue necrosis, which is a point of least resistance in and about which 
infection is prone to occur. 

Catgut. — The favorite ligature material is catgut. Catgut undergoes ab- 
sorption in the tissues. Years ago attempts were made by Scarpa, Crampton, 
and Physick to use absorbable ligatures. Sir Astley Cooper tried catgut. 
These attempts failed because the material employed was septic, suppuration 
ensued, the wound gaped, and the ligature was cast off prematurely. Surgeons 
remained content with non-absorbable ligatures of silk or linen. These 
ligatures were not cut short, but a long end was left to each one, and the 
ends were allowed to hang out of the wound. The ligatures were lightly 
pulled upon from time to time, and when they loosened or cut through were 
removed. Catgut is the submucous coat of the intestine of the sheep, and 
is the material from which violin strings are made. It was reintroduced into 
surgery by Lister. It is obtained in the following manner: The small intestine, 
after separation from the mesentery, is washed in water, laid upon a board, 
and scraped with a metal instrument. Thus the mucous coat and the muscular 
coat are scraped away, and the submucous coat only remains. The sub- 
mucous coat is cut into strips, and each strip is twisted into a coil. Raw cat- 



64 Asepsis and Antisepsis 

gut is an infected material. It is difficult to sterilize, because in the twisting 
many organisms get into the interior of the strand, where it is impossible for 
antiseptics to reach them. Raw catgut obtained from animals dead of 
splenic fever contains spores of anthrax. If not thoroughly disinfected, catgut 
is dangerous, and some surgeons consider its cleanliness always a matter 
of grave question and will not use it. Surgeon's catgut can be bought from 
the dealer in skeins containing 30 yards. It should be rough and yellow. 
The smooth white variety should not be gotten. It has been rubbed smooth 
with a piece of glass and bleached with a chemical, and in consequence is 
weak and unreliable. The smallest size is known as double zero, then come 
single zero, No. 1, No. 2, No. 3, and No. 4. The usual ligature size is No. 
2. Nos. 3 and 4 are only used for tying thick pedicles. Nos. 1 and 2 are used 
for suturing the dura and peritoneum, and No. 1 for tying small vessels in the 
brain. McBurney and Collins state that when catgut is used to tie delicate 
tissue (omental masses, intestinal surfaces, etc.), it must first be softened by 
immersing for half a minute in normal salt solution. If this precaution is 
neglected and wiry catgut is used, the ligature or suture will cut and hemor- 
rhage will occur.* The greater the diameter of the gut the more uncertain 
is the sterilization. Nos. 3 and 4 are of doubtful cleanliness, no matter what 
method of sterilization is employed, and a strand though clean upon the sur- 
face may be infected in its interior. When a strand which is infected within 
is used by the surgeon the tissues are not infected promptly but after some 
days when the catgut has been partially absorbed and the spores or bacteria 
within the strand have been set free. Many late infections are due to catgut 
infected in the interior of the strand. The smaller sizes I believe can usu- 
ally be satisfactorily sterilized. 

If catgut is thoroughlv freed from bacteria, and the wound in which it is 
used is aseptic, it is a most satisfactory ligature material, is absorbed in the 
wound after being cut off short, and produces no trouble although it does in- 
crease slightly wound secretion. The smaller sizes are absorbed in four or five 
days, No. 2 lasts from nine to ten days, Nos. 3 and 4 from ten days to three 
weeks. 

One of the following methods of preparation may be used: 

Boiling in A Icohol. — The catgut is soaked in ether for twenty- four hours 
to remove fat. It is then wound on glass spools, transferred to alcohol, and 
boiled under pressure. The boiling is conducted in a heavy metal jar with 
a well-fitting screw-top. The jar is half filled with alcohol. The spools of 
catgut are placed in the jar, the lid of the jar is screwed down, and the 
apparatus is immersed in boiling water for half an hour. The gut is kept in 
this jar until needed. Fowler's catgut is prepared by boiling in alcohol. It 
is placed in hermetically sealed U-shaped glass tubes. Each tube contains 
alcohol and 12 ligatures. The alcohol is boiled by immersing the tube in boil- 
ing water. 

The Cumol Method. — The cumol method is employed by Kelly in the 
Johns Hopkins Hospital, and is known as Kronig's method. Cumol is a 
fluid hydrocarbon which boils at i79°C. Catgut is wound upon spools of 
glass, and these are placed in a beaker glass, the bottom of which is covered 
with cotton. A bit of cardboard is placed on top of the beaker, and through 
* "International Text-Book of Surgery." 



Ligatures and Sutures 65 

a small perforation in the cardboard a thermometer is introduced. The 
beaker is placed in a sand-bath and the bath is heated by means of a Bunsen 
burner. The temperature is gradually raised to 8o° C, and is kept at this 
point for one hour, in order entirely to remove moisture from the gut. Cumol, 
at a temperature of ioo° C, is poured into the glass, and the heat is increased 
until the temperature of the cumol is a few degrees below its boiling-point 
(165 C). For one hour this temperature is maintained. Then the cumol 
is poured off and the catgut is allowed to remain for a time in the sand- 
bath at a temperature of ioo° C, in order to dry. It is transferred for keeping 
into sterile glass jars or test-tubes.* 

The Claudius Method. — The iodin catgut is prepared by the Claudius 
method. Mr. Moynihan, of Leeds, makes Claudius catgut as follows: In 10 
ounces of sterile water dissolve 1 ounce of crystals of iodid of potassium. 
When all the crystals are dissolved add 10 ounces of sterile water and then 
add 1 ounce of iodin in crystalline form. Dilute the mixture with 4 pints of 
sterile water. The result is a 1 per cent, solution of iodin and potassium 
iodid. After the usual preliminary preparation, place the gut in the mixture 
and keep it in it for at least eight days before using. It can be kept in it 
without harm for a number of months. 

The Formalin Method. — The formalin method is advocated bv the elder 
Senn. The catgut is wound on glass test-tubes, and is immersed in an aque- 
ous solution of formalin (2-4 per cent.) for twenty-four to forty-eight hours. 
It is placed in running water for twelve hours to get rid of the formalin. It 
is boiled in water for fifteen minutes, is cut in pieces and tied in bundles, 
is placed in a glass-stoppered jar, and is kept ready for use in the following 
mixture: 950 parts of absolute alcohol, 50 parts of glycerin, and 100 parts of 
pulverized iodoform. Every few days the mixture should be shaken. 

Senn's process is a modification of Hoffmeister's. Even sterile catgut 
contains a toxic substance which increases wound secretion, has a poisonous 
effect on body-cells, and favors to some extent limited suppuration. Senn 
maintains that to counteract this influence gut should not only be sterile, 
but should be antiseptic, to inhibit the growth of pyogenic organisms which 
reach the wound from without during operation or subsequently by the blood. 

Dry Heat Method. — Boeckman wraps catgut in paraffin paper, seals it in a 
paper envelope, puts it in the sterilizer, and subjects it to dry heat. For three 
hours it is heated to a temperature of 284 F., and for four hours to a tem- 
perature of 290 F. The envelope can be carried in the pocket or the instru- 
ment bag. When the gut is wanted the end of the envelope is torn off, an 
assistant with sterilized hands unwraps the paraffin paper, and the gut is 
dipped for a moment in sterile water to make it pliable. f 

Corrosive Sublimate Method. — A method which has been largely used 
is to take raw catgut, keep it in ether for twenty-four hours, soak it for twenty- 
four hours in an alcoholic solution of corrosive sublimate (1 : 500^, wind it 
on sterilized glass rods, and place it for keeping in ether or in alcohol. 

Johnston's quick method of preparing catgut is as follows: Place it for 
twenty-four hours in ether; at the end of this period place it in a solution 

*See McBurnev and Collins, in "International Text-Book of Surgery," and Clark, in 
"Johns Hopkins Hospital Bulletin," March, 1896. 

f James E. Moore, in "Phila. Med. Journal," June 22, 1898. 
5 



66 Asepsis and Antisepsis 

containing 20 grains of corrosive sublimate, 100 grains of tartaric acid, and 
6 ounces of alcohol. The small gut is kept in this for ten or fifteeen minutes, 
the larger gut from twenty to thirty minutes, but never longer. It is placed 
for keeping in a mixture containing 1 drop of chlorid of palladium to 8 ounces 
of alcohol. This gut is strong and reliable. At the time of operation the gut 
is placed in a solution one-third of which is 5 per cent, carbolic acid solution 
and two-thirds of which is alcohol. 

Preparation of Chromicized Catgut. — Chromicized catgut is absorbed 
less rapidly by the tissues than ordinary catgut. It is used to tie thick 
pedicles and large arteries, to suture nerves and tendons, and as a suture 
material in the radical cure of hernia. Chromicized gut, No. 3 and No 4, 
will remain unabsorbed in the tissues from four to six weeks. The gut 
should be soaked in ether for twenty-four hours, and be immersed for twenty- 
four hours in a 4 per cent, solution of chromic acid in water. The gut is 
then dried in a hot-air sterilizer and is disinfected by one of the several 
methods. The cumol method is satisfactory. 

How to Tie Catgut. — Catgut is tied in a reef knot (square knot) and dis- 
tinct ends are left on cutting. The second knot, if pulled too tightly, may 
break the ligature. Moist catgut is slippery and is hard to tie. If a large 
vessel is tied by catgut, a third knot should be used and the ends cut close 
to the knot. Really strong catgut can be tied in a surgeon's knot. 

Kangaroo-tendon and Its Preparation. — This material is obtained from 
the tail of the great kangaroo. It is especially useful for buried sutures in 
hernia operations; it will be absorbed in the tissues, but only after a long 
time (sixty to seventy days). Kangaroo-tendon is not grossly infected as is 
catgut. The material is obtained from a recently killed animal and is promptly 
dried in the sun. This suture material was introduced by Dr. Henry O. 
Marcy. It can be prepared in the same manner as the chromicized catgut, 
and it ought always to be chromicized. Marcy's plan of preparation is as 
follows: Soak the dried tendon in a solution of corrosive sublimate (1 : 1000) 
and separate the individual strands. The individual strands will be of equal 
diameter and from 10 to 20 inches in length. The diameter depends on the 
size of the animal. Dry each strand in an antiseptic towel. Chromicize the 
tendons and keep them until needed in boiled linseed oil containing 5 per 
cent, of carbolic acid. Before using the strands take them out of the oil, 
wipe off the oil with a sterile towel, and immerse the tendon for half an hour 
in a 1 : 1000 solution of bichlorid of mercury. This immersion does not make 
them swell and soften and does not weaken them as it would catgut. 

The following method of preparation is recommended by Charles Truax 
("Mechanics of Surgery"): Soak the dried tendon until it becomes supple, 
in a 1 : 1000 solution of corrosive sublimate. Separate the material into 
individual tendons, place them lengthwise between two towels; dry them; 
make them aseptic by soaking in a solution of formalin, as we would do with 
catgut (see above). After washing out the formalin chromicize the tendon 
by placing it in a fresh 5 per cent, solution of carbolic acid containing 1:4000 
parts of chromic acid. When the tendons become "dark golden brown" in 
color, they are removed from the chromic acid solution, dried between sterile 
towels, and placed for keeping in 10 per cent, carbolized oil. When wanted, 
they are removed from the oil, and wiped with a sterile towel saturated with 
bichlorid solution (1 : 1000). Kangaroo-tendon is tied in a reef knot. 



Ligatures and Sutures 67 

Silk. — This material can be used for both ligatures and sutures; many 
sizes should be kept on hand. Silk is very strong, soft, extremely supple, 
and does not swell or irritate the tissue. It can be tied into very firm knots. 
Ordinary surgical silk is a form of twisted silk — that is, several or many strands 
are twisted into one. Cable twist or Tait's silk is very strong and is used for 
tying large pedicles. Braided silk is extremely strong and is made by plaiting 
together several strands of twisted silk. Floss silk is " a straight fiber slightly 
twisted" (Truax). Silk is usually tied in a reef knot, but occasionally in a 
surgeon's knot. White silk may be used, or black silk, which is more easily 
visible. Silk becomes encapsuled in the tissues. It is not absorbed at all 
or only after a very long time. It is not a good material for buried sutures, 
as in the long run it may form a sinus. 

Preparation of Silk. — Sutures of silk should be boiled for half an hour before 
using in a 1 per cent, solution of carbonate of sodium. Some surgeons keep 
the silk after boiling in sublimated alcohol (1 : 1000) or carbolic solution (5 
per cent.), but it is better to prepare it just before using. A convenient method 
of preparation is to wind the silk on a glass spool, place the spool in a large 
test-tube, close the mouth of the tube with jewelers' cotton, introduce the tube 
into a steam sterilizer, and subject it to a pressure of 10 pounds for twenty 
minutes, repeating the process the next day. These tubes are carried in 
wooden boxes sealed with rubber corks. 

Horsehair and Its Preparation. — This is used foreffecting very neat approxi- 
mation where only light sutures are required; for instance, in wounds of the 
face. Its chief use is for capillary drainage. It is prepared by washing and 
then boiling for fifteen minutes in a 4 per cent, solution of carbonate of sodium. 
It is kept until needed in sublimated alcohol (1 : 1000). 

Silkworm-gut and Its Preparation. — This material contains fewer bacteria 
than catgut and does not swell when introduced into a wound. It is strong, 
solid, smooth, non-irritating, can be drawn through the tissues with slight 
force, and does not tend to cut the tissue as does a metallic suture. The 
designation silkworm-gut is a misnomer; the material is not gut at all but 
is obtained from the silk-producing glands. Italy supplies most of the 
gut used by fishermen but the gut used by the surgeon comes chiefly from 
Murcia in Spain. When the silkworms are just ready to spin they are 
placed in vinegar and water for a number of hours and are thus killed. Each 
worm is opened and the silk-producing glands are clearly exposed and each 
gland is drawn by its ends into a single thread. The threads are dried in 
the air and assume a reddish color (M. J. Triollet, in "Bulletin des Sciences 
Pharmacologiques," 1905, No. 5. Quoted in "Lancet," Feb. 3, 1906). 
" This crude silkworm-gut is sold to the manufacturer and further treated. It is 
first boiled in alkaline water to remove fat and blood and is then dried in the 
sun, being protected from dust. It is next polished by means of slightly oiled 
pumice stone. The gut is then bleached with sulphurous acid and rubbed 
vigorously with chamois leather to remove dust and sulphur" ("Lancet," 
Feb. 3, 1906). It is a very valuable material but is not used for ligatures as it 
cannot be tied as firmly as catgut and because when left buried in the tissue 
the sharp ends may sitck and irritate and a point of least resistance may 
be created. Silkworm-gut is prepared by placing it in ether for forty- 
eight hours and in a solution of corrosive sublimate (1 : 1000) for one hour, 



68 



Asepsis and Antisepsis 



or it can be boiled in plain water for half an hour. It is carried in a long 
tube filled with alcohol. A few minutes before using the gut is placed in car- 
bolic acid and alcohol (one-third of the solution is a 5 per cent, solution of 
acid, two-thirds of it is alcohol). Silkworm-gut is tied by the surgeon's knot. 
Celluloid Thread and Its Preparation. — This material is warmly advocated 
by Pagenstecher. He calls it celluloid yarn, and prepares it from English 
gray linen thread. I have used it with much satisfaction. It is strong, smooth, 
flexible, and the knot holds firmly; it can be sterilized by any method used 
for raw silk, and sterilization by dry heat actually increases its strength. Its 
one disadvantage is that it absorbs about 40 per cent, of fluid, but does not 
soften. The celluloid is added after 
the thread has been boiled in a 1 per 
cent, solution of carbonate of soda 
wiped or wrapped in a sterile towel and 
dried in hot air or steam. It is then 
dipped in a solution of celluloid heated 





Fig. 37.— Arnold steam sterilizer 
(Fowler). 



Fig. 38. — Small steam-pressure sterilizer and 
instrument boiler (Fowler). 



in a hot-air sterilizer, and packed in sterile boxes (Schlutius, in "Pacific Med. 
Journal," Jan., 1900; Keen and Rosenberger, in "Phila. Med. Journal," 
May 10, 1900). Celluloid thread can be used for sutures or ligatures. 

Silver wire is prepared by boiling. It is a very useful suture material, as 
it can be thoroughly sterilized and has an inhibitory effect on the growth of 
bacteria. Some surgeons use it for buried sutures, but many are opposed to 
using it thus on the ground that it is apt to lead to sinus-formation. 

Most wounds are closed by interrupted sutures of silkworm-gut, but silk, 
catgut, chromic catgut, or silver wire can be used. The old continuous 
suture (glovers' stitch) is rarely used except as a buried suture. An admir- 



Dressings 



69 



able closure can be effected by Halsted's subcuticular stitch, and scarcely any 
scar results (page 51). Marcy's buried tendon sutures are very valuable, 
especially in hernia operations and in various operations upon the abdomen. 

Dressings are made of cheese-cloth. In order to make antiseptic gauze 
the cheese-cloth is boiled in a solution of carbonate of sodium, rinsed out, 
and dried; it is then soaked for twenty-four hours in a solution containing 1 
part of corrosive sublimate, 2 parts of table salt, and 500 parts of water. It 
is placed in clean jars with glass lids, and it may be kept moist or dry. 

Sterilized or aseptic gauze is prepared by boiling in carbonate of sodium 
solution, etc., as described under Antiseptic Gauze. The gauze is then 
wrapped in a towel and is placed in a steam sterilizer (Figs. 37, 38, and 39) 
for an hour. It is kept until wanted in sterile glass jars with glass lids. The 
pads for sponging are made by rolling up portions of sterile gauze. Ashton's 
abdominal pads are made by taking several layers of sterile gauze, each piece 





Fig. 39. — Lautenschlager's steam sterilizer for dressings: A, Exterior view; B, cross-section. 



about six inches long and four inches wide, running a stitch around the mar- 
gin, and sewing a piece of tape into one corner. 

Sterile absorbent cotton is prepared in the same manner as gauze. Cotton 
is useful as a dressing to supplement gauze, being placed on the outside of the 
gauze. It absorbs quantities of serum, but will take up very little pus. 

Iodoform gauze is very useful for packing in the brain and abdomen, for 
packing abscesses and tuberculous areas, and for dressing foul wounds. It 
is prepared as follows : Make an emulsion composed of equal parts by weight 
of iodoform, glycerin, and alcohol, and add corrosive sublimate in the pro- 
portion of 1 part to 1000 of the mixture. This mixture stands for three 
days. Take moist bichlorid gauze, saturate it with the emulsion, let it drip 
for a time, and keep it in sterilized and covered glass jars (Johnston). 

Lister's cyanid gauze (double cyanid of zinc and mercury) is not certainly 
antiseptic, and must be dipped into a corrosive sublimate solution (1 : 2000) 
before using. All forms of gauze can be bought ready prepared from reliable 
firms. 



70 Asepsis and Antisepsis 

Some surgeons place silver foil upon a wound before applying the gauze 
(Halsted, page 31). Small wounds in which drainage is not employed may 
often be dressed by laying a film of aseptic absorbent cotton over the wound 
and applying, by means of a clean camel's-hair brush, iodoform collodion 
(grs. xlviij of iodoform to §j of collodion). Among other materials sometimes 
used for dressing wounds the following should be mentioned: Wood wool, 
absorbent wool, moose pappe, oakum, jute, peat, and sawdust. 

Protectives. — A protective is a material placed directly upon wounds to 
shield them from irritation and infection and outside of dressings to diffuse and 
prevent the escape of discharge. The commonly used protectives are Lister's 
oil silk protective, gutta-percha tissue, rubber dam, waxed paper, paraffin 
paper, mackintosh, and silver foil. Undoubtedly, many antiseptic agents 
destroy young cells and in this way hinder repair. The same is true of certain 
rough dressings. 

R. T. Morris showed us that gauze and particularly cotton are injurious 
to a healing wound. A non-irritant protective laid directly upon a wound 
may be useful by saving new cells from injury by an irritant germicide and 
from being pulled away at each change of dressings. 

Among the best protectives in common use are Lister's protective, gutta- 
percha tissue, and silver foil. Morris condemns gutta-percha tissue as irri- 
tant. He uses thin gold-beaters' skin made from the peritoneum of the ox, 
which material he calls Cargile membrane, after an Arkansas physician who 
introduced it into practice. The advantage of this material is that moisture 
cannot penetrate and new cells do not adhere. I have used it with satisfac- 
tion in some cases but in wounds and ulcers prefer silver foil (see "An Experi- 
mental and Histological Study of Cargile Membrane," by A. B. Craig and 
A. G. Ellis, "Annals of Surg.," June, 1905). 

Silver foil, Lister's protective, or gutta-percha tissue is laid directly 
upon a wound, the dressing being placed above it. Silver foil comes in books 
and is sterilized by dry heat. Gutta-percha tissue it sterilized by washing 
with soap and water, rinsing in sterile water, and soaking in a solution of 
corrosive sublimate. Lister's protective is employed to save the wound from 
the irritation of carbolized dressings. In the United States, if it is desired to 
place an impermeable material over a dressing, a rubber dam is usually em- 
ployed. A rubber dam before being used should be washed with soap and 
water and soaked in a solution of corrosive sublimate. 

The use of an impermeable material on the outside of the gauze dressing 
is not nearly so common as formerly. In an aseptic wound dry dressing un- 
covered by rubber is the most useful. When a dressing is covered by an 
impermeable material it becomes wet, acts as a poultice, and the discharges 
on the dressings may undergo decomposition. 

Drainage. — Drainage is used in all infected wounds, in most very large 
wounds, in wounds to which irritant antiseptics have been applied, in cases 
in which large abnormal cavities exist, in very fat people, and in individuals 
with such thin skin that we dare not apply firm pressure (see page 52). 
Drainage is obtained, when needed, by rubber or glass tubes, by strands of 
horsehair, silkworm-gut or catgut, by pieces of gauze, and occasionally in 
the abdomen by Mikulicz's bag or tampon by which we obtain pressure to 
arrest hemorrhage and also secure drainage (Fig. 43). Rubber drainage 



Removal of Stitches 




Fig. 40.— Drainage-tubes ; A, Glass; B, Rubber. 



tubes (Fig. 40, B) are rendered sterile by boiling in plain water. They are kept 
until wanted in a mercurial solution. This solution should be changed even- 
few days, because the mercurv is 
apt to be precipitated as sulphid. 
Glass tubes are sterilized by boil- 
ing. A bit of rubber tissue is 
sometimes used for drainage. 
Gauze, catgut, etc., are known 
as capillary drains. When moist 
they drain serum excellently, but 
pus very badly or not at all. Pus 
requires tubular drainage. Drainage-tubes or strands are brought out at a 
portion of the wound which will be dependent when the patient is recum- 
bent. 

Change of Dressing. — When a change of dressings is determined upon 
the surgeon should carefully sterilize his hands and forearms and should have 
at hand a warm solution of corrosive sublimate, common salt solution, an 
irrigator, iodoform, iodoform gauze, scissors, forceps, basins (Figs. 41 and 42), 

etc. Dressings should 
be moistened before re- 
moval with salt solution 
or corrosive sublimate 
solution. If they stick 
to the part a spray of 
hydrogen dioxid' pro- 
jected from an atomizer 
between the skin and 
dressings will soon loosen 
them. Dressings must be changed as soon as soaking with blood or wound- 
fluid is apparent. If the wound becomes uneasy and painful or if con- 
stitutional symptoms of wound infection arise the dressings must be removed 
to permit of inspection of the wound. A change of dressings must be 
effected with all of the aseptic care employed in a surgical operation. 
Dressings are not dispensed with until the wound is soundly healed. 

Removal of Stitches. — Buried 
stitches of animal material are not 
removed by the surgeon but are 
gradually absorbed in the tissues. 
Buried stitches of silk or silver wire, 
which are used by some surgeons, 
although they are not absorbed in 
the tissues, may never require re- 
moval but in some cases cause 

sinuses to form and a sinus from a suture or ligature will not heal until the 
suture or ligature is removed. 

If a catgut stitch is passed through the skin and tied externally the loop 
in the tissue is absorbed but the knot and remainder of the loop is on the 
surface and is not absorbed but remains adherent to the wound and the sur- 
geon need only lift it off with forceps. Catgut is used as a material for cuta- 




Fig. 41. — Smith's dressing basin. 




Fig. 42.— Plain dressing basin 



7 2 



Asepsis and Antisepsis 




Fig. 43. — Mikulicz's bag; a, Ab- 
dominal sutures; 6, gauze bag; c, 
abdominal wound; d, loops in the 
abdominal wall; e, gauze strip. 




Fig. 44. — Method of ex- 
traction of a suture (Es- 
march and Kowalzig). 



neous suturing in the operation of circumcision. When a skin wound is 
closed by unabsorbable sutures, as it usually is, the surgeon at the proper 
time takes forceps and scissors and removes the stitches. Stitches may 
usually come out from the sixth to the eighth day, although if there is 
much tension on the edges of the wound they are allowed to remain several 
days longer. In large wounds, half of the stitches are taken out at one 

time, the remainder being allowed to remain 
for a couple of days longer. When a stitch 
begins to cut, it is doing no good, and it should 
be removed, no matter how short a time it has 
been in place. If it is allowed to remain, it will 
cut into the wound, make a stitch-abscess, and 
cause an irregular suture-line. In order to 
remove a stitch pick up 
an end distal from the 
knot with forceps, lift it 
lightly, cut one side of 
the suture close to the 
skin by scissors, and re- 
move it by pulling in the 
direction of the side on 
which the suture was 
cut (Fig. 44). 

Artificial Sponges. — Bits of gauze should be used, each piece being 
thrown away as soon as it is soaked with blood or tissue fluid. Gauze 
pads can be used, soaking them in an antiseptic solution and squeezing them 
out from time to time during an operation. 

Preparation of Marine Sponges. — Marine sponges are seldom used. 
Gauze pads are preferred. Marine sponges absorb admirably, but they 
are hard to clean when new and cannot be certainly sterilized in their inte- 
riors after becoming infected. They may be prepared as follows: Beat out 
the dust; place them for forty-eight hours in a solution of hydrochloric acid 
(15 per cent.); wash them with water; place them for one hour in a solution 
of permanganate of potassium (5iij to 5 pints of water); soak for four hours 
in a solution containing 10 ounces of hyposulphite of sodium, 5 ounces of 
hydrochloric acid, and 3 pints of water; wash with running water for six 
hours. Keep the sponges in a jar containing corrosive sublimate solution 
(1 : 1000). After using, wash in hot water, soak for half an hour in a solution 
of sodium carbonate (1 132), wash again in hot water, and replace in cor- 
rosive sublimate. 

Senn's Decalcified Bone-chips. — Take the shaft of the tibia or femur 
of a recently killed ox, saw it into portions two inches in length, remove the 
marrow and periosteum, and place the fragments of bone in a 15 per cent, 
solution of hydrochloric acid. Change the solution every twenty-four hours. 
In from two to four weeks the bone will be decalcified. Wash in distilled 
water, place the pieces of decalcified bone for a few minutes in a dilute solu- 
tion of potash to neutralize the acid, and then immerse for twenty-four hours 
in distilled water. The portions of bone are cut into strips in the direction 
of the long axis of the segments. Each strip is three-quarters of an inch wide 



Active Hyperemia 73 

and should be sliced into bits one millimeter thick. These chips are kept in 
an alcoholic solution of corrosive sublimate (1 : 500). 

Bandages. — For retaining dressings upon wounds the unbleached muslin 
bandage may be used, but in most cases the gauze bandage is employed. The 
gauze bandage soaked in corrosive sublimate solution is antiseptic; it does not 
partly seal the dressing and act like protective; it can be applied firmly, evenly, 
and rapidly, and is very comfortable. 



III. INFLAMMATION. 

Definition. — When the tissues are injured they react or respond, and 
this reaction or response is known as inflammation. The process of inflam- 
mation was defined by the late Sir John Burdon-Sanderson as "the succession 
of changes which occur in a living tissue when it is injured, provided that the in- 
jury is not of such a degree as at once to destroy its structure and vitality." Pro- 
fessor Adami, in his article upon inflammation in Allbutt's "System of Medi- 
cine," points out that this definition really includes too much. He alludes 
to the hemorrhage which occurs in the liver after a traumatism, and the sub- 
sequent changes in the extravasted corpuscles, and points out that these 
changes are not inflammatory phenomena. This definition, however, includes 
all inflammatory conditions, is largely employed, is very useful, indicates the 
cause, and, as Burdon-Sanderson says, makes clear that inflammation is a 
process and not a state (Adami). Adami's definition is as follows: "The 
series of changes constituting the local manifestation of the attempt at repair 
of actual or referred injury to a part, or, briefly, the local attempt at repair of 
actual or referred injury." The changes alluded to in Burdon-Sanderson's 
definition comprise (1) changes in the vessels and the circulation, (2) depar- 
ture of fluids and solids from the vessels, and (3) changes in the perivascular 
tissues. 

Vascular and circulatory changes were formerly thought to be 
absolutely essential to inflammation in both vascular and non-vascular tissues. 
In the former they occur in the inflamed tissues; in the latter (cornea and 
cartilage) they are manifest in neighboring tissues from which the non-vascular 
area derives its nutritive material. As a matter of fact, in inflammation, 
vascular changes are almost always present; but in a rather trivial corneal 
inflammation the episcleral vessels may not dilate, and the onlv white corpus- 
cles which gather in the damaged area are those which come from the lvmph- 
spaces of the cornea. Inflammation in any tissue will not be accompanied 
by vascular dilatation unless the process reaches a certain stage of severitv. 

Active Hyperemia. — When an irritant is applied to tissue there may 
be a momentary arterial contraction due to irritation of the nerves, but this 
contraction is transitory, and is not an inflammatory phenomenon. The 
first vascular phenomenon is dilatation of all the vessels, — capillaries, venules, 
and arterioles, — appearing first and being most pronounced in the small 
arteries. As a result of the dilatation there are increased rapidity of circula- 
tion and increased determination of blood to the part, and the area of hvper- 
emia becomes warmer than is normal. This condition of increased circulatory 
activity is known as "active hyperemia" (Fig. 46). 



74 



Inflammation 



Active hyperemia is an increase in the amount of moving blood in a part. 
Passive hyperemia is an increase in the amount of blood in a part, but not of 
moving blood, as passive hyperemia or congestion is due to venous obstruction, 
and the blood is stagnated. Diminution in the amount of blood in a part is 
ischemia. Local anemia is the complete cutting-off of the blood-supply of a 
part. 

In active hyperemia more blood goes to the part and more blood passes 
through it, an increased amount of venous blood comes from the hyperemic 
area, the venous tension is increased, and the veins may even pulsate. The 
capillaries, which under ordinary circumstances contain but few blood-cells 
(Fig. 45), become filled with corpuscles (Fig. 46), and even the smallest capil- 
laries pulsate. The blood in the veins adjacent to the area of inflammation 
is of a much lighter red than in health. Many capillaries which were invisible 

under normal conditions become visible 
when active hyperemia exists. The capil- 
laries contain no muscle-fiber, and hence 
these tubes cannot actively contract, except 
so far as the caliber of the tubes is altered 
by the contraction or expansion of the 
endothelial cells of the capillary wall. 
Contraction and dilatation of the capilla- 
ries depend chiefly on the amount of 
blood sent to or retained in them. In 
active hyperemia the increased amount 
of blood sent to the part causes capillary 
dilatation. As a result of the dilatation 
the endothelial cells become thinner than 
before, the cells as a result of irritation lose 
some of their power to restrain exudation, 
and some observers assert that openings 
are formed between the cells or that pre- 
viously existing openings enlarge (page 
77). Fluid elements rarely leave the blood- 
vessels during active hyperemia, but they 
occasionally do. The wheals of urticaria are thus formed (Warren). Active 
hyperemia is often the first stage of an inflammation, but it is not of neces- 
sity followed by other inflammatory changes, and it can be caused by nerve 
section or nerve stimulation. 

The duration of active hyperemia is variable. If the irritation was brief, 
the hyperemia is very transitory. In some cases dilatation with accelerated 
circulation is scarcely more than momentary, giving way almost immediately 
to dilatation with retardation. If the irritation is prolonged, hyperemia may 
last some time before giving way to retardation. In the web of a frog's foot, 
if an irritant is applied, hyperemia lasts from one-half hour to two hours 
before it is replaced by retardation. 

Clinical Signs 0} Active Hyperemia. — A hyperemic part, if on or near 
the surface, is red in color, imparts a sense of heat to the examining hand, 
the color quickly disappears on pressure and quickly returns when pressure 
is released. In a congested part the temperature is diminished, the surface 




Fig. 45. — Normal vessels and blood-stream. 



Oscillation and Stagnation 



75 



is purple, the congested veins are visible, there are edema and a sensation of 
coldness and numbness. When congestion is purely local, the lividity dis- 
appears quickly when pressure is applied and returns quickly when pressure 
is removed. When due to disease of the heart or lungs, it disappears and 
returns slowly. When a local congestion is about to give way to gangrene, 
the lividity disappears very slowly on pressure and crawls back slowly when 
pressure is released. 

Retardation. — After active hyperemia has existed for a variable time 
the blood-current begins to lessen in velocity, until it becomes more tardy than 
in health. This is known as "retardation of the circulation." Retardation 
is first noted in the venules, next in the capillaries, and last in the arterioles; 
but arterial pulsation continues. The red cells take the center of the blood- 
stream, which is known as the axial current. The white corpuscles drop out 
of the central stream, separate from the red, and float lazily along near the 
vessel-wall, and they are accompanied by many third corpuscles. The white 
cells show a strong tendency to adhere to the venule-walls, and, as a result, 
accumulate against the inside of, and stick to, these walls and to one another, 
until the venules are entirely lined with layers of leukocytes (Fig. 47). The 
third corpuscles act in a similar man- 
ner and take the peripheral current. In 
the capillaries some leukocytes gather, 
but not many. In the arterioles they 
adhere during cardiac dilatation, but 
are swept away by the force of the 
heart's contractions. Retardation is 
believed to be chiefly due to paresis of 
the muscular walls of the arterioles. 
This causation seems probable when 
we recall Lord Lister's experiments 
upon the pigment-cells of the frog's 
foot. Lister proved that inflammation 
paralyzes the pigment-cells, and con- 
cluded that dilatation at the focus of 
an inflammation is due to the paralyz- 
ing action of an irritant. Dilatation 
at a distance from the focus is a reflex 
phenomenon (W. Watson Cheyne). 
When the vessels are weakened or 
paralyzed, the contractions of the arte- 
rioles are feeble or absent, and the blood is no longer urged forward by arterial 
power. The endothelial cells of the small vessels enlarge distinctly during 
retardation and develop a condition of stickiness, which leads the white cells 
to adhere to them, and thus increases resistance to the current of blood and 
adds to retardation. Fluids pass through the wall of a vessel in this con- 
dition more readily than through a healthy vessel, and white corpuscles 
leave the vessel in large numbers. 

Oscillation and Stagnation. — By this accumulation of leukocytes 
the blood-stream is progressively narrowed and the axial current is impeded. 
The red blood-cells begin to stick to one another, forming aggregations like 




Fig. 46. — Dilatation of the vessels in inflammation. 



76 



Inflammation 



rouleaux of coin, which masses increase the difficulty the axial current has to 
contend with, until progressive movement ceases and the contents of the vessels 
sway to and fro with each heart-beat. This is the stage of oscillation. In a 
short time oscillation ceases and the vessels are filled with blood which does 
not move, and the vessel-walls become irregular in outline or even pouched. 
This stage is known as "stasis" or "stagnation." Stasis is chiefly due 
to paralysis and damage of the vessel- walls. Migration ceases when stasis 
takes place. If stasis persists, coagulation occurs, because the vessel-walls 
have been so injured by the irritant as to be practically dead material, and they 
are no longer able to prevent clotting of their contents. Finally, in persisting 
stasis the vessel- walls rupture or are entirely destroyed. 

Resume of the Vascular Changes of Inflammation. — We can sum up 
the vascular changes of inflammation by stating that they consist in a dilatation 
of the small vessels and a primary acceleration, a secondary retardation, and a 
subsequent stagnation of the blood-current, exudation of blood-liquor, adhe- 
sion of leukocytes to the walls of veins and capillaries, migration of leukocytes, 
the aggregation of the red blood-cells into intravascular masses, and coagulation 

of the material remaining in the vessel. 
Exudation of Fluids.— It is to 
be remembered that in the process 
of nutrition blood-liquor and also white 
cells pass into the tissues through the 
walls of veins and capillaries, and dur- 
ing this process certain other materials 
are passing from the tissues into the 
vessels. Hence, a diffusible irritant 
in the vessels may pass into the tissues 
and a diffusible irritant in the tissues 
may pass into the vessels. Whenever 
retardation of the circulation arises, 
there is an increase in the amount of 
plasma which passes out of the vessels, 
but in inflammation the exudation 
into the lymph-spaces is vastly greater 
in amount and is different in com- 
position. In a slight inflammation, 
and in the early stage of any in- 
flammation, there is an increase in the 
fluid exudate, and we speak of the con- 
dition as "serous inflammation." This fluid is really not serum, but is liquor 
sanguinis. We find .true serum in passive congestion, not in active inflam- 
mation. The fluid in a serous exudation contains very few white cells, and 
hence little or no fibrin can form in it, and coagulation does not take place in 
the perivascular tissues; and if the inflammation goes no further, the exudate 
is absorbed by the lymphatics. A blister is an example of serous inflamma- 
tion. If the inflammation continues to intensify, the exudation is altered 
in character — it becomes thicker, turbid, and very coagulable and exhibits 
a greatly increased bactericidal power. It contains many white cells and 
fibrin elements, and coagulates in the tissues, because some of the leukocytes 




Fig. 47. — Retardation of blood and migration of 
white corpuscles in inflammation. 



Exudation of Fluids 77 

break up and set free fibrin ferment, and fibrin ferment causes the union of 
calcium and fibrinogen and the formation of fibrin. This fluid exudate is 
known as "lymph," or plastic exudation, and when it is present wespeak of the 
condition as "plastic inflammation. " Lymph can be seen in the anterior 
chamber of the eye in cases of plastic iritis. Coagulated fibrin in a recent 
wound causes the edges to adhere or glazes the raw surface. In inflammation 
of a mucous surface it may appear as a false membrane. In inflammation of 
serous surfaces it may glue the surfaces together and lessen motion, the fibrin- 
ous masses which effect the gluing being called fibrinous or plastic adhesions. 
These adhesions within the abdomen may seal a perforation, may cover a raw 
spot, or may encompass an area of infection and prevent fatal diffusion. 
Further fibrin surrounds and entangles bacteria and retards their diffusion. 
Pyogenic cocci lessen, retard, or prevent fibrin formation or destroy fibrin previ- 
ously formed. The fibrinous adhesions may, of course, do harm. They may 
retard or prevent the absorption of exudate; they may narrow and obstruct 
important structures (bowel, urethra, larynx), they may bind up and cripple an 
important viscus (liver, heart or brain). Fibrinous adhesions may be succeeded 
by dense contracting and constricting bands of fibrous tissue. The lymphatics 
endeavor to absorb the fluid exudate in inflammation, but become occluded 
by coagulation, and the area they drain becomes swollen, hard, and "brawny." 
The slighter the inflammation, the less albuminous is the fluid; the more in- 
tense the inflammation, the more albuminous is the fluid. The focus of an 
inflammation usually feels brawny because of coagulation of a highly albumin- 
ous exudate; the periphery of an inflammation is soft and edematous because 
of the presence there of thin and non-coagulable exudate. Inflammatory 
lymph contains proteids and other substances. "Of these the more important 
are ferments, the results of proteolysis (notably fibrin and its precursors and 
peptones), and in many cases mucin, together with bactericidal substances, and, 
where bacteria are present, the products of their growth." * The amount of 
the exudation varies with the violence of the irritation, the nature of the irri- 
tant, the general condition of the organism, and the state of the tissues which are 
involved. In dense tissue (bone, periosteum, etc.) the exudation is scanty. 
In loose tissues (subcutaneous tissue) it is profuse. Profuse exudation may 
take place into a joint, the pleural sac, the peritoneal cavity, or the peri- 
cardium. In such cases the exudation is profuse because the serous mem- 
brane has a thin covering of endothelium, contains quantities of vessels, and the 
vessels receive but a thin covering and obtain but a scant support towards the 
cavity. 

Does the plasma leave the vessels as a simple filtrate? Some maintain 
that it does. Heidenhain and others claim that it does not, and believe that 
the endothelial cells play an active part in the process. Heidenhain likens 
exudation to secretion, because some materials from the plasma pass out 
and others do not. Adami is inclined to agree with Heidenhain, that the 
epithelium plays "not a passive, but an active role." Are there spaces between 
the endothelial cells of the capillary? It was long taught positively that there 
are no open spaces between the endothelial cells of the vessel-wall, and that 
these cells are held close together by a cement substance. It is now believed 
by some observers that spaces exist between the protoplasmic strands which 
* Adami, in Allbutt's "System of Medicine." 



78 



Inflammation 



hold the cells together, these spaces being closed when the vessel is contracted 
and open when the vessel is dilated. When these spaces are open fluid passes, 
and through these doorways leukocytes emerge. 

Migration and Diapedesis. — Even early in an inflammation some few 
white corpuscles pass through the vessel-walls; but when the inflammation 
is well established, large numbers, and when it is severe vast hordes, pass into 
the perivascular tissues. This process is known as " migration" (Figs. 47 and 






Fig. 48. — Stages of the migration of a single white blood-eorpuscle through the wall of a vein (Caton). 



48) . The leukocytes throw out protoplasmic arms, insert themselves between 
the cells of the walls of the vessel, and pull themselves through by their power 
of ameboid movement (Fig. 49). Some observers claim that they do not pass 
through existing open doors, but form openings which close after them. This 
is readily accomplished, because the vessel-wall is itself damaged, weakened, 
and convoluted. Others claim that stomata exist between the endothelial 

cells, the vessel-wall being 
porous likea filter (page 77). 
The escape of leukocytes 
takes place chiefly from the 
venules, though some mi- 
grate through the capillaries 
and even the arterioles (Fig. 

47)- 

The leukocytes are in- 
fluenced to move toward the 
damaged tissue by the at- 
tractive force known as posi- 
tive " chemiotaxis" a force 
which draws them toward 
invading bacteria, to regions of irritation, and to areas of tissue death. 
Leukocytes may move from very virulent organisms, influenced by what is 
known as negative "chemiotaxis." The migration of a leukocyte requires 
but a short time. Fig. 48 shows the migration of a white blood-cell through a 
vein-wall, the process requiring one hour and fifty minutes. In very acute 
inflammations red corpuscles also pass into the tissues. Red corpuscles are not 




Fig. 49. — Ameboid movements of a leukocyte (Warner). 



Changes in the Perivascular Tissues 79 

capable of ameboid movements, and if they do escape from the vessels the 
process is passive on their part and not active. This passive escape happens 
because the capillary walls have been destroyed or because stomata have been 
greatly enlarged by vascular dilatation. If red corpuscles do pass into the 
exudate, as happens in pneumonia, the inflammation is a very severe one and 
is called a hemorrhagic inflammation. The escape of corpuscles by a passive 
process is known as "diapedesis," in contra-distinction to the escape of 
leukocytes by active ameboid movements, a process known as "migration." 
The white corpuscles usually greatly increase in number in the blood of a 
person who has an acute inflammation, and the blood-making organs, such as 
the spleen and lymphatic glands, are often enlarged. An increase of white 
corpuscles in the blood of an individual is called leukocytosis. 

Blood Plaques. — Blood plates, blood plaques, or third corpuscles, may be 
discovered in freshly drawn blood, but, unless they are present in unusual num- 
bers, they will rarely be seen in specimens prepared in the usual way. The 
third corpuscles can be seen by a high power microscope in the moving blood 
of the web of a frog's foot. In blood outside of the body they are destroyed as 
soon as coagulation begins, and in order to see them coagulation must be 
prevented. Some observers maintain that the third corpuscles are the real 
fibrin-formers. The blood plaques, or third corpuscles, are found to be present 
in increased numbers in inflammation. In health their usual proportion to 
red cells is as 1 to 20. They are especially numerous at the height of fever 
processes and during convalescence from an extensive abscess. 

Changes in the Perivascular Tissues.— The cells of the peri- 
vascular tissue are phagocytes and when stimulated they enlarge, become 
more actively phagocytic, and undergo reproduction. The liquor sanguinis 
which exudes during an acute inflammation coagulates unless prevented by 
virulent bacteria. It has often been asserted that exudation is Nature's 
method of supplying nutriment to the cells of the damaged region. Adami 
points out the apparently contradictory observation that the amount of exu- 
date is in direct proportion to the rapidity of cell-destruction, but nevertheless 
concludes that exudation stands in close relation with cell-proliferation.* 
From whatever cause, tissue-cells multiply, and this process is known as 
" cell- pr operation." 

When a tissue is injured it inflames, and, as Adami points out, the reaction 
we call inflammation is an attempt to repair injury. 

Irritation may lead to degeneration and death of cells; it may lead to 
growth and multiplication. In many cases both processes are active in the 
acute stage, the cells at the focus of the inflammation undergoing degeneration 
and destruction, and those at the boundary undergoing growth and prolifera- 
tion.! 

If tissue-cells have been seriously damaged, they perish, and new cells are 
required to replace them. The inflammatory process has led to exudation 
of plasma and migration of leukocytes into the perivascular tissues. The 
connective-tissue cells multiply and produce young cells, which are known 
as " fibroblasts," and which eat up many leukocytes. Early in an inflammation 
polynuclear leukocytes preponderate, later mononuclear phagocytic cells 

* Adami, in Allbutt's "System of Medicine." 
f Adami, in Allbutt's " System of Medicine." 



So Inflammation 

predominate (Opie). The leukocytes contain two enzymes. One is derived 
from bone marrow and digests proteid in an alkaline medium; the other is de- 
rived from lymph-glands and digests proteid in an acid medium (Opie). The 
migrated leukocytes in part surround the inflamed region and retard diffusion 
of the process. Many enter the diseased area and attack bacteria. Some 
undergo degenerative changes and liberate fibrin ferment which makes the 
exudate clot. Some move out of the inflamed area, each one carrying within 
it tissue debris, and many are eaten up by the fibroblasts. There is no real 
proof that leukocytes proliferate and help directly to form new tissue. This 
mass of young cells, taking origin from the fixed cells, has been called em- 
bryonic tissue, because of a fancied resemblance to the cells of the embryo. 
John Hunter called it juvenile tissue. It has also been called indifferent tissue, 
because of the belief that it could be converted indifferently into various tissue 
according to circumstances. It is also spoken of as inflammatory new for- 
mation. 

An exudation may be absorbed by the lymphatics. It may be converted 
into pus if infected with pyogenic bacteria, or be replaced by cells from the 
proliferation of fixed tissue-cells, the cellular mass being subsequently vascu- 
larized by the extension into it of capillary loops derived from adjacent capil- 
laries. When embryonic tissue is filled with blood-vessels, — that is to say, 
when it is vascularized, — it is called granulation tissue. Granulation tissue 
is finally converted into fibrous tissue. The above complicated processes, 
vascular and perivascular, are not accidents nor haphazard freaks, but are 
Nature's efforts to bring about a cure. 

Dilatation is due to the direct effect of the irritant upon the muscle or its 
nerve-elements. Retardation and stasis are due to paralysis of the vessel- 
wall, which paralysis causes resistance to the passage of the blood-stream 
and adhesion of the leukocytes to the vessel-wall. The blood-liquor exudes 
and the leukocytes migrate. Often these efforts of Nature succeed. Accel- 
eration of the circulation may succeed in washing away an irritant from the 
vessel-wall. By bringing quantities of blood to the part it secures copious 
exudation of plasma. The exudation may wash and remove irritants from 
the tissues, and the germicidal blood-liquor may destroy bacteria in the 
damaged area. The migration of corpuscles may prove of great service. 
The leukocytes surround an area of infection and tend to limit its spread. 
Leukocytes have phagocytic properties, and energetically attack and often 
destroy bacteria, and they furnish enzymes which may digest proteids and 
antitoxins which antagonize and may neutralize the poisons produced by 
micro-organisms. Leukocytes aid in forming fibrin. Fibrin formation is of 
service by helping immobilization and by hindering the spread of bacteria. 
Leukocytes also aid in separating dead tissue from living, and they remove 
tissue debris from the area of inflammation. The multiplication of the fixed 
connective-tissue cells leads to the formation of fibroblasts, and fibroblasts are 
converted into fibrous tissue, which effects permanent repair (these changes 
will be alluded to again in the section on Repair). 

Nature may fail in her efforts. For instance, an enormous exudate in- 
creases stasis and may cause such tension that gangrene results. 

Inflammation in Nonvascular Tissue.— A type of non-vascular 
tissue is the cornea, and the cornea can inflame. The healthy cornea contains 



Classification of Inflammations 81 

no blood-vessels. It is formed of many layers of fibers, each layer running 
parallel with the corneal surface and forming angles with the fibers of the 
adjacent layers. Between the layers are communicating lymph-spaces con- 
taining connective-tissue cells known as corneal corpuscles. It obtains its 
nourishment in part from the vessels of the conjunctiva, but chiefly from the 
vessels of the ciliary body and sclera. When the cornea inflames, the epi- 
scleral, conjunctival, and ciliary vessels usually dilate and pour out exudate, 
and the fluid exudate and the leukocytes enter into the corneal lymph-spaces. 
The exudate coagulates and cell-multiplication ensues as in any other in- 
flammation. In mild inflammations the vessels about the cornea may n< >t dilate. 
Leukocytes, from the lymph-spaces, reach the seat of injury in small numbers, 
and the fixed cells multiply. Xancrede points out that in trivial inflammation 
which injures but does not destroy the epithelium leukocytes may not go to 
the seat of inflammation, the only change being enlargement and multipli- 
cation of corneal corpuscles. If new formation takes place, a permanent 
opacity mars the cornea as a consequence. 

Cartilage has no blood-vessels except in regions where growth is very active 
or where ossification is taking place. Cartilage has no spaces, like the cornea, 
for a free circulation of lymph. In man canals have not been demonstrated 
and it is thought that fibrils conduct nutritive fluids, the nutritive plasma flow- 
ing between the cells, but there is no direct connection with blood-vessels. The 
plasma is furnished by the vessels at the margin of the perichondrium. Carti- 
lage can inflame and an inflammation of this structure is slow in evolution and 
of long duration. When inflammation occurs, the cartilage cells enlarge and 
their nuclei proliferate, the intercellular substance softens and cartilage cells 
mav be cast off. After a long time vessels may invade the inflamed cartilage 
and fibrous tissues form from the perichondrium, but in some cases a loss of sub- 
stance is not repaired. 

Inflammation of Mucous Membrane. — It may be catarrhal, suppura- 
tive, croupous, or diphtheritic. In a catarrhal inflammation the increased 
blood-supply causes an excessive flow of mucus. The submucous tissues 
present the ordinary changes of inflammation and quantities of epithelial 
cells are cast off from the surface. Fibrous tissues may form in the sub- 
mucous tissue and thus cause permanent thickening (strictures, etc.). 

Suppurative inflammation is usually preceded by catarrhal inflammation. 
In this condition the discharge is mucopurulent and ulcers are apt to form. 
A trivial loss of substance permits of regeneration, but a considerable loss is 
repaired by fibrous tissue which by its bulk and by contracting may interfere 
greatly with the functional usefulness of an organ or a canal. 

A croupous inflammation is one in which quantities of epithelial cells are 
cast off the surface and there forms upon the surface a highly fibrinous ex- 
udate (false membrane). 

In diphtheritic inflammation the mucous membrane is destroyed and the 
false membrane invades the submucous tissue. Diphtheritic inflammation 
is due to a specific bacillus. 

Classification of Inflammations. — The various forms of inflamma- 
tions are — (i) Simple or common, that which is due to any ordinary traumatic, 
chemical, thermal, or actinic cause, and not to bacteria, such as traumatic 
periostitis or sun dermatitis. It does not tend particularly to spread. As a 
6 



82 Inflammation 

rule, the cause of a simple inflammation is momentary in action; (2) infec- 
tive or specific, that which is due to micro-organisms, as the streptococcus of 
erysipelas. An unsuccessful attempt has been made to charge all inflamma- 
tions to bacteria. It is true that bacteria can generally be found in inflamma- 
tory areas, but that they are the only causes of inflammation is accepted by 
few. Infective inflammations often tend to spread widely; (3) traumatic, 
which is due to a blow or an injury; (4) idiopathic, which is without an ascer- 
tainable cause. There is certainly a cause, even if it cannot be pointed out, 
and the term "idiopathic" means that we do not know the cause; (5) acute, 
which is rapid in course and violent in action; (6) chronic, which follows a 
prolonged course; (7) subacute, which is intermediate in violence and dura- 
tion between acute and chronic; (8) sthenic, characterized by high action. 
Occurs in strong young subjects; (9) asthenic or adynamic, occurring in the 
old, the debilitated, and the broken-down. In such an inflammation there 
is no certain limitation of the inflammation by leukocytes, and there is an 
indisposition on the part of the tissue-cells to form fibroblasts; (10) paren- 
chymatous, affecting the "parenchyma," or active cells of an organ; (11) 
interstitial, affecting the connective-tissue stroma of an organ; (12) serous, 
characterized by profuse non-coagulating exudation (as in pleuritis) or by 
marked inflammatory edema; (13) plastic, adhesive, or fibrinous, character- 
ized by an exudation which glues together adjacent surfaces, as in peritonitis; 
(14) purulent, phlegmonous, or suppurative, when pyogenic cocci are present 
and multiply; (15) hemorrhagic, when the exudate contains many red blood- 
cells, as in strangulated hernia and in the pustules of black smallpox; (16) 
croupous, when an inflammation produces upon the surface of a tissue a 
fibrinous exudate which cannot be organized into tissue, and which is due to 
the action of micro-organisms. An exudate of this character was called by 
the older surgeons " aplastic lymph." It occurs most usually on mucous 
membrane; (17) diphtheritic, which differs from croupous in the fact that 
the false membrane is in the tissue rather than upon it; (18) gangrenous, an 
inflammation resulting in death of the part, the gangrene being due to the 
tension of the exudate or the virulence of the poison; (19) healthy, when the 
tendency is to repair; (20) unhealthy, when the tendency is to destruction; 
(21) latent, an inflammation which for some time does not announce itself by 
any obvious symptoms, as the inflammation of Peyer's patches in typhoid 
fever; (22) contagious, when its own secretions can propagate it; (23) dry, 
without exudation; (24) hypostatic, arising in a region of passive congestion 
(as a bed-sore); (25) malignant, due to a malignant growth; (26) catarrhal, 
affecting a mucous membrane; (27) neuropathic, due to impairment of the 
trophic functions of the nervous system, as in perforating ulcer; and (28) 
sympathetic or reflex, due to disease or injury of a distant part, as when orchitis 
follows mumps. 

Extension of Inflammation. — Inflammation extends by continuity 
of structure, by contiguity of structure, by the blood, and by the lymphatics. 
Extension by continuity is seen in phlebitis. Extension by contiguity is 
seen when a cutaneous inflammation advances and attacks deeper struc- 
tures. Extension by the blood is seen in the formation of the smallpox 
exanthem. Extension by the lymphatics is witnessed in a bubo following 
chancroid. 



Terminations of Inflammation 83 

Terminations of Inflammation.— Inflammation may be followed by 
a return of the tissues to health, and this return may take place by delites- 
cence, by resolution, or by new growth. By delitescence is meant abrupt 
termination at an early stage, as when a quinsy is aborted by the administra- 
tion of quinin and morphin, and the production of a sweat; resolution means 
the gradual disappearance of the symptoms when inflammation has passed 
through its regular stages ; and new growth means that an inflammation has 
lasted a considerable time, with ample blood-supply, and without suppuration 
and has gone on to the formation of fibroblasts, granulation tissue, and fibrous 
tissue. Inflammation may be followed by death of the inflamed part, or 
necrosis. Death of the part may be due to suppuration, ulceration, or gan- 
grene. 

The causes of inflammation are— predisposing, or those residing in 
the tissues, and rendering them liable to inflame; and exciting, or those which 
directly awake the process into activity. The first may be thought of as 
furnishing inflammable material; the second may be regarded as sparks of 
fire. 

Predisposing causes are those which impair the general vigor, injure the 
blood, weaken the tissues, or lower nutritive activities. Among these causes 
are shock, hemorrhage, nervous irritation, gout, rheumatism, diabetes, 
Bright's disease, alcoholism, and syphilis. Plethora renders a person liable 
to sthenic inflammations (those characterized by high action). Tissue 
debility renders one prone to adynamic or asthenic inflammations. Nerve 
injury predisposes to inflammation, either from damage to trophic nerves and 
consequent failure in tissue nutrition and resistance or because analgesia exists 
and irritants which reach the region are not recognized and are allowed to 
remain. For instance, if the conjunctiva is in a condition of analgesia, the 
presence of foreign bodies is not noticed and destructive inflammation may 
result from their non-removal. 

After removal of the Gasserian ganglion the cornea is devoid of sensation, 
the flow of tears is lessened, dust gathers in the eye, and if not removed by 
irrigation or kept out by a shield inflammation and disastrous ulceration will 
ensue. 

Exciting Causes. — The exciting causes of inflammation are — traumatic, 
as blows and mechanical irritation; chemical, as the stings of insects, the 
rubefacient effects of mustard, venom of serpents, products of bacteria, 
ivy poison, etc.; thermal, heat and cold; specific, the micro-organisms, caus- 
ing, for instance, tuberculous peritonitis or erysipelas; and nervous, nerve stimu- 
lation certainly being capable of producing hyperemia and sometimes even 
inflammation. Inflammation due to nerve stimulation is seen in herpes zoster 
and in the swollen and discolored skin over an inflamed joint (Adami). Inflam- 
mation may also be induced by electric currents, by the .r-rays, by radium 
rays, and by the actinic rays of sunlight and of electric light. 

Some writers insist that every inflammation is due to the action of micro- 
organisms, but this statement lacks proof. They maintain that inflammation 
is a destructive microbic process which cannot bring about repair, and that 
repair begins only when inflammation ends. As Adami points out, the advo- 
cates of this view argue that swelling, pain, and discoloration point to the 
existence of inflammation; that repair can take place when these phenomena 



84 Inflammation 

are absent, hence inflammation is not present when repair begins. As a matter 
of fact, swelling, discoloration, and pain are phenomena often but not inva- 
riably associated with inflammation; and in inflammation one or all of 
these phenomena may be absent. Because these signs are not discovered is 
no proof that inflammation does not exist. I believe that inflammation is 
not always due to microbes and is not always a destructive process, but may 
be from the start conservative and reparative. It is the reaction of the tissue 
to injury and is the first step on the road to repair.* 

Symptoms of Acute Inflammation. — Inflammation, if at all severe, 
announces its presence by symptoms which are both local and constitutional. 
The local symptoms are heat, pain, discoloration, swelling, disordered function, 
and in some regions muscular rigidity; the chief constitutional symptom is fever. 

Local Symptoms of Inflammation. — The most prominent local symp- 
toms were known centuries ago to the famous Roman, Celsus, who stated them 
as "rubor, color cum tumore et dolore" — redness and heat with swelling and 
pain. As set forth to-day, the local symptoms are — (i) heat; (2) pain; (3) 
discoloration; (4) swelling; (5) disordered function; and (6) muscular 
rigidity, which is noted in inflammation of certain regions and structures. 

Heat is due to the passage of an increased quantity of blood through the 
damaged area and to the arrival at the surface of the body of warm blood 
from internal parts. Although an inflamed part may be, and usually is, 
warmer than the surrounding parts, its temperature is never greater than the 
temperature of the blood. This increase of heat is especially noticeable when 
we, for instance, touch an arm affected with erysipelas and contrast the sensa- 
tion obtained with that obtained by placing the hand on the sound arm. 
The diseased arm feels much warmer to the examining hand than does the 
sound arm, but its temperature is not above the general body-temperature . 
An extremity in health, as is well known, shows on the surface a temperature 
below that of the blood; in an inflamed state the temperature may nearly equal 
that of the blood. Heat is always present in inflammation of a superficial 
part. The surgeon examines for heat by placing his hand upon the suspected 
area and then placing it upon a corresponding portion of the opposite side 
of the patient in order to note the contrast. If great accuracy is desired, a 
surface thermometer is used. 

Pain is a constant and conspicuous symptom. It is due to stretching 
of or pressure upon nerves from exudate; to irritation of nerves; or to inflam- 
mation of the nerves themselves, producing cellular changes. Pain is asso- 
ciated with tenderness (pain on pressure), it is aggravated by motion and by 
a dependent position of the part, and it varies in degree and in character. In 
serous membranes it is acute and lancinating, like dagger-thrusts; in connec- 
tive tissue it is acute and throbbing; in large organs it is dull and heavy; in 
the bone it is gnawing or boring; in the skin and mucous membrane it is 
itching, burning, smarting, or stinging; in the urethra it is scalding; in the 
testicle it is sickening or nauseating; in the teeth it is throbbing; and in in- 
flammation under dense fascia it is pulsatile. Pain in inflammation after 
presenting itself in one form may change in character. If a pain becomes 
markedly throbbing, suppuration may be anticipated. Pain does not always 
occur at the seat of trouble, but may be felt at some distant point. This is 
* See Adami's masterly article in Allbutt's "Svstem of Medicine." 



Local Symptoms of Inflammation 85 

known as a "sympathetic " pain, and is due to the fact that the area to which 
pain is referred receives its nerve-supply from the same spinal segment as does 
the inflamed area, in other words, there is a nervous communication between 
the inflamed part and a distant area. In most cases of sympathetic pain a 
nerve-trunk refers the sense of pain to its peripheral distribution but some- 
times pain is referred to an adjacent nerve, a distant nerve, or even, perhaps, 
to a nerve on the opposite side of the body. Tenderness, however, is de- 
tected at the seat of trouble and not at the seat of referred pain. 

Pain 0} hepatitis is often felt in the right shoulder. Pain at the point of 
the shoulder or in the shoulder-blade is felt also in gall-stones and in cancer 
of the liver. The pain arises in filaments of the pneumogastric from the 
hepatic plexus, which filaments reach the spinal accessory, pain being ex- 
pressed in the branches of the spinal accessory which supply the trapezius 
and communicate with the third and fourth cervical nerves.* 

Pain of coxalgia is often felt on the inside of the knee, because the obturator 
nerve, which sends a branch to the ligamentum teres, also sends a branch to 
the interior and to the inner side of the knee-joint. 

Inflammation of an eye with increased tension causes browache. In- 
flammation of the neck of the bladder causes pain in the head of the penis. 
Inflammation oj a testicle cause pain in the groin. Renal calculus and pyelitis 
cause pain in and retraction of the testicle, and pain in the loin, groin, or thigh. 

If the covering of an organ is involved, pain becomes more violent; for 
instance, hepatitis becomes much more painful when the perihepatic structures 
are attacked. Inflammation without pain is known as "latent" (as the in- 
flammation of Peyer's patches in typhoid). The sudden disappearance of 
inflammatory pain, when not due to the administration of opiates, suggests 
the possibility of gangrene, because analgesia exists in gangrene. The 
characteristics of inflammatory pain are that it comes on gradually, has a fixed 
seat, is continuous, is attended by other inflammatory symptoms, and is 
increased by motion, by pressure, and by a dependent position of the part. 
If there be no tenderness in a part, the source of the pain is not local inflam- 
mation; but tenderness may exist when there is no local inflammation, as in 
pain referred from a distant part. Pain of inflammation does not correspond 
to an exact nervous distribution. If pain corresponds exactly to the area of 
a nerve's distribution, the cause of it is acting on the nerve-trunk or on its 
roots. If the cutaneous surface is involved, the lightest touch causes pain. 
If touching the skin produces no pain, but deep pressure does produce it, 
the deeper structures are the source. Pain in muscle and ligament is devel- 
oped by motion; in muscle, by contraction, but not by passive movements 
with the muscle relaxed; in ligament pain is developed by active or passive 
movements which stretch the ligament. If, for example, a man with a stiff 
neck has pain on the right side of the back of his neck on voluntarily turning 
his face toward the left shoulder, but is without pain when his face is turned 
by the surgeon, who, conversely, induces pain by turning the patient's face far 
to the right, this condition indicates the trouble to be muscular. If, however, 
no pain arises on turning the face to the right, but it is manifest ^m turning the 
face actively or passively to the left, the pain is in those ligaments which stretch 

*Embleton's view in Hilton on " Rest and Pain," a book every 1 student should read. 



86 Inflammation 

when the face is turned to the left.* In inflammation of the synovial mem- 
brane gentle passive motion in any direction causes pain. 

The pain of colic differs from that of inflammation. It is sudden in onset, 
intermits, recurs in paroxysms, and is relieved by pressure. The pain of 
inflammation is gradual in onset, is continuous, and is made worse by pressure. 
The pain of neuralgia is often preceded by cutaneous anesthesia of the skin 
of the part, is very paroxysmal, comes on suddenly, darts through recognized 
nerve-areas, the attack lasts some hours, and is apt to recur at a certain hour. 
It presents no general tenderness, as does inflammation, but we may find 
serveral points which are acutely sensitive to pressure (Valleix's points dou- 
loureux). The tender spots of Valleix are met with in inveterate neuralgia, 
and occur at points where nerves " pass from a deeper to a more superficial 
level, and particularly where they emerge from bony canals or pierce fibrous 
fasciae. "f 

Pain is often of great value by calling attention to parts diseased; but it 
may be a terrible evil, racking the organism and even causing death. If pain 
continues long, it becomes in itself formidable: it prevents sleep, it destroys 
appetite, and it deteriorates the mind, and one of the surgeon's highest duties 
is to relieve it. The physiognomy or expression of physical pain presents the 
following characteristics: Heavy fulness about the eyes, and dropping of the 
angles of the mouth, added to appearance due to anemia, widespread tremor, 
etc. The absence of the physiognomy of pain in a person who complains of 
great agony is a strong indication that the patient exaggerates the gravity of 
his sufferings or deliberately deceives. 

Discoloration arises from determination of blood to the part; hence the 
more vascular the tissue, the greater the discoloration. A non-vascular tissue 
presents no discoloration, though we usually find discoloration adjacent in the 
zone of blood-vessels which furnish the tissue with nutriment. Discoloration 
is most intense at the focus or center of inflammatory action. Discoloration 
varies in tint and in character according to the tissue implicated and the nature 
of the inflammation. It may be circumscribed or diffuse. Arborescent 
redness means a distribution in dendritic lines. Linear discoloration signifies 
redness running in straight lines, as in phlebitis. Punctiform discoloration 
occurs in points, and is due to vascular rupture. Maculiform redness re- 
sembles an ecchymosis or blotch. Dusky discoloration points to suppuration. 

Inflammation of the throat and skin produces scarlet discoloration; in- 
flammation of the sclerotic coat of the eye and of the fibrous coat of muscle 
produces lilac or bluish discoloration; inflammation of the iris produces brick- 
dust, grayish, or brown discoloration; erysipelas causes a yellowish-red dis- 
coloration; secondary syphilis causes a copper-hued discoloration; and ton- 
sillitis causes a livid discoloration. A tuberculous ulcer is of a purple color 
on the edge. Gangrene is shown by a black discoloration. A scorbutic ulcer 
is surrounded by an area of violet color. 

Redness as a sign of inflammation must be permanent and joined with 
other symptoms. Redness due to inflammation disappears on pressure, but 
returns as soon as the pressure is removed. If redness is due to staining of 
the surface by dye, pigmentation, or extravasation of blood, pressure will not 

*" Surgical Diagnosis," by A. Pearce Gould. 

f Anstie, " Neuralgia and Diseases which Resemble It." 



Impairment of Special Function 87 

blanch the spot. If on taking off pressure the redness of inflammation rapidly 
returns, the circulation is active; if, on the contrary, it very slowly reappears, 
the circulation is very sluggish and gangrene is threatened. Subcutaneous 
hemorrhage gives rise to a purple-red color which does not fade when sub- 
jected to pressure. Stains of the surface by dyes fail to disappear on pressure, 
are distributed over a considerable surface, show a hue which is uniform 
throughout, are obviously superficial, are not associated with other signs of 
inflammation, and can be washed away. 

A. Pearce Gould, in his excellent little work upon " Surgical Diagnosis," 
tells us that the color of a hyperemic surface may furnish important informa- 
tion. Lividity may mean failure of the heart and lungs, or simply venous 
congestion in the part. In lividity from obstruction of the lungs or heart the 
color slowly returns after pressure has driven it out. In lividity due to local 
congestion the color quickly returns when pressure is released and the dilated 
veins are often distinctly visible. Of course, in a local trouble, when the 
circulation becomes impaired to such a degree that gangrene is threatened, 
the lividity fades very slowly on pressure and reappears very slowly on the 
release of pressure. 

Swelling or tumefaction arises in small part from vascular distention, but 
chiefly from effusion and cell-multiplication. The more loose cellular mate- 
rial a part contains, the more it swells; hence the eyelids, scrotum, vulva, 
tonsils, glottis, and conjunctivas swell very largely when inflamed. A swelling 
is soft or edematous when due to uncoagulable effusion; is brawny and doughy 
when due to coagulated effusion; is hard and elastic when produced by pro- 
liferating cells. Swelling may do good by unloading the vessels and acting 
like a blister or local bleeding, or it may do great harm by pressing upon the 
vessels and cutting off the blood-supply. Swelling of the conjunctiva, or 
chemosis, may cause sloughing of the cornea, and swelling of the prepuce 
may cause gangrene. A swelling may do harm by obstructing a natural 
passage, as in edema of the glottis, when the larynx becomes blocked; or by 
compression of a normal channel, as in the swelling of the perineum, when 
the urethra is compressed. A swollen area may be covered with blisters or 
blebs. This condition is noted particularly in burns and fractures. 

Disordered junction is always present in inflammation. It may be mani- 
fested by increased tenderness or sensibility, a slight touch, it may be, pro- 
ducing torturing pain. Parts almost or entirely destitute of feeling when 
healthy (as tendons, ligaments, and bones) become highly sensitive when 
inflamed. It may be manifested by increased irritability. In dvsentery the 
colon repeatedly contracts and expels its contents; the stomach does likewise 
in gastritis; and the bladder acts similarly in cystitis. Spasmodic twitching 
of the eyelids occurs in conjunctivitis, and twitching of the muscles of a limb 
in fracture and after amputation. 

Impairment oj Special Function. — In inflammation of the eve, when an 
attempt is made to look at objects, the lids close spasmodically, and even a 
little light causes great pain and lachrymation (photophobia). In inflamma- 
tion of the ear noises cause great suffering, and even when in a quiet room the 
patient has subjective buzzing and roaring in his ears (tinnitus aurium). 
In coryza the sense of smell, in glossitis the sense of taste, in dermatitis the 
sense of touch, and in laryngitis the voice may be lost. In inflammation of 



88 Inflammation 

the brain the mind is affected; in arthritis the joints can scarcely be moved; 
and in myositis it is difficult and painful to employ the muscles. 

Derangement of Secretions. — In dermatitis the sweat it not thrown off; in 
hepatitis bile is not properly secreted; and in nephritis urea is not satisfac- 
torily removed. The secretions may undergo important changes of compo- 
sition. The sputum in pneumonia is rusty, and dysentery causes a discharge 
of bloody mucus (Gross). 

Derangement of Absorbents. — In the height of an inflammation the absor- 
bents are blocked and clogged by coagulated exudate, and they cannot perform 
their offices. 

Muscular rigidity is sometimes an important sign of inflammation. If 
a joint is inflamed the muscles which move the joint are rigid and the joint 
is more or less immobile. In inflammation of the peritoneum the abdominal 
muscles are rigid and the respirations become shallow, frequent, and thoracic. 
In pleuritis the intercostal muscles of the inflamed side become rigid and the 
respiratory excursion of the chest is limited. Rigidity serves to lessen motion, 
prevent pain, protect the part, and so give phvsiological rest. 

Constitutional symptoms of acute inflammation may be absent, and 
often are in moderate or limited inflammations; but in severe, extensive, or 
infective inflammations the symptom group known as fever is certain to exist. 
This is known as symptomatic, or inflammatory fever, and it arises in 
non-septic cases from the absorption of aseptic pyrogenous exudate and in 
microbic inflammations from the absorption of pyrogenous toxic products 
of bacterial action. In young and robust individuals an acute non-microbic 
inflammation causes a fever characterized by full, strong pulse, flushed face, 
coated tongue, dry skin, nausea, constipation, and possibily acute delirium (the 
sthenic type of the older authors). In broken-down and exhausted indi- 
viduals an ordinary inflammation, and in any individuals a bacterial inflam- 
mation, may cause a fever with typhoid symptoms (the typhoid, asthenic, or 
adynamic type). Fibrin ferment is obtained from the white corpuscles; it is 
liberated as the corpuscles break up in the exudate, and acting on the liquor 
sanguinis cause the union of calcium and fibrinogen and the formation of 
fibrin. The absorption of fibrin ferment many believe causes aseptic fever 
(page 124). Inflammatory blood contains an increased amount of albumin 
and salts. If a person with inflammatory fever is bled, the blood coagulates 
rapidly, the clot sinks, and there is found on the surface a cup-shaped coat, 
made up oHiquor sanguinis and white cells, known as the u buffy coat" '; but 
this is not really a sign of inflammation, and occurs normally in the blood of 
the horse. The buffy coat forms when blood contains a great number of leu- 
kocytes, because these leukocytes sink more slowly than do the red corpuscles. 
Cupping occurs because the white corpuscles sink more slowly by the side 
of the tube than far from the sides. 

Leukocytosis. — In many inflammatory and infectious diseases leukocy- 
tosis is noted. It probably indicates an attempt on the part of the organism 
to protect itself from noxious materials. Leukocytosis is usually much more 
marked if pus exists than if the exudation is serous or fibrinous. 

"The degree of leukocytosis may be considered a general index to the in- 
tensity of the infection and to the strength of the individual's resisting powers 
in reacting against it. If follows, therefore, that intense infections occurring 



Local Treatment of Inflammation 89 

in individuals' whose resisting powers are strong, produce a decided increase; 
but the presence of an infection of like intensity in one whose resisting powers 
are greatly crippled fails to cause leukocytosis, for in such an instance the organ- 
ism is so overpowered by the effects of the morbid process that it is incapable 
of reacting." (•'Clinical Hematology," by J. C. DaCosta, Jr.) 

Chronic Inflammation. — This condition results from the action on the 
tissues of some mild but long acting irritant. It progresses slowly and does not 
produce symptoms of severity either in the part or the body at large. 

Causes. — Blood diseases, as rheumatism and gout; infective diseases, as 
tuberculosis and syphilis; retained pus in an ill-drained abscess; blocking 
of the duct of a gland; the retention of a foreign body in a part: the flow of an 
irritant secretion (as saliva from a fistula); repeated identical traumatisms 
of an occupation, etc. W. Watson Cheyne tells us that chronic inflamma tion 
is not due to the ordinary pyogenic organisms (see Cheyne's article in Treves 's 
'• System of Surgery"). 

Tissue-changes. — These changes are practically the same as in acute 
inflammation, but take place far less rapidly. Vascular dilatation, exudation, 
and leukocytic migration are often trivial. Cell proliferation is alwavs con- 
spicuously marked. It is maintained by Cheyne and others that tvpical granu- 
lation tissue does not form, the tissues of the part being replaced directly by 
fibrous tissue. The amount of fibrous tissue produced is relativelv verv great. 
This tissue may cause permanent thickening, or may contract and thus dimin- 
ish the size of a part. Contraction is very considerable in cirrhosis of the liver 
and in interstitial nephritis. 

Symptoms. — Pain varying in intensity and character; tenderness; great 
swelling, which in some cases is followed by shrinking, and is usually indurated 
or brawny. As a matter of fact, great swelling is the most usual symptom. 
Sometimes there is a trivial amount of heat. There is rarely discoloration 
unless the skin is itself inflamed, but usually the surface veins are distinctly 
and sometimes they are greatly distended. There are no constitutional 
symptoms attributable purely to the inflammation. If there are such svmp- 
toms, they are due to the disease which induced the inflammation or to inter- 
ference with the function of an organ because of the fibrous mass. (For the 
treatment of chronic inflammation see articles upon special regions and par- 
ticular structures.) 

Treatment of Acute Inflammation.— The first rule in treating an 
inflammation must be to remove the exciting cause. If this cause is a splinter 
in the part, take out the splinter; if it is a foreign body in the eye, remove the 
foreign body; if urine is extra vasated, open and drain; take off pressure from 
a corn; pull out an ingrown nail; and remove microbes from an infected area 
by exposing, irrigating, and applying antiseptics. The rule, remove the cause, 
applies to a chronic as well as to an acute inflammation. If the cause of an 
inflammation was momentary in action (as a blow), we cannot remove it, for 
it has already ceased to exist. After removing the cause, endeavor to bring 
about a cure by local and constitutional treatment. 

Local Treatment of Inflammation. — It must be remembered that the 
division of inflammation into stages is natural, and not artificial, and that a 
remedy which does good in one stage may do harm in another. Certain agents 
are suited to all stages of an acute inflammation, namely, rest and elevation. In 



9° 



Inflammation 



many inflammatory conditions Nature seeks to immobilize, protect, and rest 
the part by increasing the tension of adjacent muscles. By this muscular 
rigidity inflamed joints are fixed and rested. Rigidity of the intercostal mus- 
cles in pleuritis limits chest motion and pain; rigidity of the abdominal mus- 
cles in peritonitis limits abdominal movements and lessens suffering. 

Rest. — Physiological rest is of infinite importance, and is always indicated 
in acute inflammation. In the exercise of function blood is taken to a part 
and an existing inflammation is aggravated. Further, as Billroth has pointed 
out, rest prevents the dissemination of infection, because motion exposes 
fresh surfaces to inoculation and breaks down protective barriers of leuko- 
cytes. Its principles were first thoroughly studied by Hilton.* Baron Larrey, 
the celebrated military surgeon of the Napoleonic Empire, anticipated many 
modern views on this subject. He insisted on the necessity of rest in the 
treatment of wounds; he believed that rest permitted Nature to perform 
her work unhampered; he was accustomed to leave a "first dressing," if 
properly applied, undisturbed for several or even for many days. He believed 
it advisable to associate with rest well adjusted and judicious compression 
made by bandages, especially flannel bandages. (The author on Baron 
Larrey, in "Johns Hopkins Hospital Bulletin," July, 1906.) The means of 
securing rest differ with the structure or the part diseased. When rest is 
used, do not employ it too long. Rest in bed diminishes the amount of blood 
sent to an inflamed part and lessens the force of the circulation; hence it 
antagonizes stasis. It has been shown that the heart beats at least fifteen 
times per minute less when the patient is recumbent than when he is erect. 
The saving of strength and the benefit to the local condition are thus seen to 
be enormous. In fact, the heart saves at least twenty-one thousand beats a 
day. In every severe inflammation insist on the patient going to bed. 

In cerebral concussion rest must be secured by quiet, by darkness, by the 
avoidance of stimulants and meat, by the application of ice to the head, and 
by the use of purgatives to prevent reflex disturbance and the circulation of 
poisons in the blood. In inflamed joints rest must be obtained by proper 
position, associated in many cases with the adjustment of splints or plaster- 
of-Paris, or the employment of extension. 

In pleuritis partial rest can be secured by strapping the affected side with 
adhesive plaster or by using a bandage or a binder to limit respiratory move- 
ments. In fractures Nature procures rest by her splints — the callus — and 
the surgeon procures rest by his splints — firm dressings, or extension. In 
cancer of the rectum and intractable rectitis a colostomy secures rest for the 
inflamed and damaged bowel. In enteritis opium gives rest to the bowel by 
stopping peristalsis. In cystitis rest is obtained by the administration of opium 
and belladonna, which paralyze the muscular fibers of the bladder. The use 
of the catheter gives rest to the bladder by removing urine. A cystotomy 
allows complete rest by permitting the bladder to suspend its function as a 
reservoir of urine. In cystitis from vesical calculus rest is obtained by cutting 
or crushing the stone. In inflamed mucous membrane rest from the contact 
of irritants is secured by touching the membrane with silver nitrate, which 
forms a protective coat of coagulated albumin. Opening an abscess gives 
its walls rest from tension. In inflammations 0) the eye light must be excluded 
to obtain complete rest, but tolerably satisfactory rest is given in some cases 
*" Lectures upon Rest and Pain." 



Leeching 91 

by the use of glasses of a peacock-blue tint. In aneurysm the operation of 
ligation cuts off the blood-current and gives rest to the sac. In hernia the 
operation gives rest from pressure. Instances of the value of rest could 
indefinitely be multiplied. 

Relaxation is in reality a form of rest, and consists in placing the part in an 
easy position. In synovitis of the knee semiflexion of the knee-joint lessens 
the pain. In muscular inflammations relaxation relieves the pain. 

Elevation. — Elevation partly restores circulatory equilibrium. A jelon 
is less painful when the hand is held up in a sling than when it is dependent. 
A congestive headache is worse during recumbency. A gouty inflammation 
in the great toe is more painful with the foot lowered than when it is raised. 
A toothache becomes worse on lying down. 

Certain agents are suited to the stage of vascular engorgement, increased 
arterial tension, and beginning effusion. These agents are — (1) local bleed- 
ing or depletion; (2) cutting off the blood-supply; and (3) cold. 

Local Bleeding. — Local bleeding, or depletion, is the abstraction of blood 
from the inflamed area. This abstraction relieves circulatory retardation 
and causes the blood to move rapidly onward; the corpuscles clinging to the 
vessel-walls are washed away, the capillaries shrink to their natural size, and 
the exudate is absorbed. In other words, local blood-letting increases the 
rate of the circulation, though not its force. 

The methods 0) bleeding locally are — (a) puncture; (b) scarification; (c) 
leeching; and (d) cupping. 

Puncture is recommended in inflammation, not only because it abstracts 
blood locally, but also because it gives an exit to effusion under fibrous mem- 
branes. It is very useful in relieving tension — for instance, in epididymitis. 
It is performed with a tenotome and with aseptic precautions. If numerous 
punctures are made, the procedure is termed "multiple puncture." This is 
verv useful when applied to the inflamed area around a leg-ulcer. The late 
Prof. Joseph Pancoast was very fond of employing multiple punctures, desig- 
nating the operation " the antiphlogistic touch of the therapeutic knife." 

Scarification or Incision. — By means of scarification we bleed locally, 
evacuate exudate, and relieve tension. One cut or many cuts may be made, 
and these cuts may be deep or may not go entirely through the skin, according 
to circumstances. Multiple incisions are useful when applied to inflamed 
ulcers, ulcers in danger of gangrene, and to almost any condition of great ten- 
sion. Scarification is of notable value when edema of the glottis exists. Free 
incision is of great benefit in periostitis and in threatened gangrene. In osteo- 
myelitis the medullary canal must be promptly opened. 

Leeching. — Leeches must not be applied to a region plentifully endowed 
with loose cellular tissue, as great swelling and discoloration are sure to ensue. 
These regions are the prepuce, labia majora, scrotum, and eyelids. Leeches 
should never be applied to the face (because of the scar), near specific sores 
or inflammations, nor over a superficial artery, vein, or nerve. A leech is best 
applied at the periphery of an inflammation and between an inflammation 
and the heart. To leech at the inflammatory focus only aggravates the trouble. 
Before applying leeches, wash the part and shave it if hairy. Place the leech 
in a test-tube or an inverted wine glass, inserting the tail or thick end first, 
and invert the tube so that the leech's head will come in contact with the pre- 



02 



Inflammation 



pared skin. The leech is restrained in the tube until it "takes hold" and 
begins to feed, when the tube is removed. If the leeches will not bite, smear 
the part with milk or a little blood. Never pull off a leech; let it drop off. 
It will usually drop off when full, but if it refuses to do so, sprinkle it with salt. 
After removing a leech, employ warm fomentations if continued bleeding is 
desired. Sometimes the bleeding persists, but this may be arrested by styptic 
cotton and pressure. In some rare cases the bleeding continues in spite of 
pressure. This is due to the fact that the tissue contains 
a considerable quantity of a material secreted from the 
throat of the leech, which material prevents coagulation 
of blood. In such a case excise the bite and the area 
of tissue adjacent to it, and suture the wound. Leech- 
ing leaves permanent triangular scars. The Swedish 
leech, which is preferred to the American, draws from 
two to four drams of blood. After a leech has been re- 
moved, if we desire to use it again, place it in salt water. 
This causes it to vomit the blood which it has taken up. 
Leeching has both a constitutional and a local effect. It 
is at present used comparatively rarely, but it is employed 
by some practitioners over the spermatic cord in epi- 
didymitis, on the temple in ocular inflammation, and 
over the right iliac region to relieve pain in mild cases of appendicitis. 

Cupping.— Dry cups deviate blood from a deeply placed inflamed area to 
the surface. Wet cups actually remove blood. 

Dry Cups. — Dry cups are applied without first incising the skin. One or 
more may be applied. A special instrument is sold in the shops for the per- 




bulb 





Fig. 51.— Scarificator. 



Fig. 52. — Heurteloup's artificial leech. 



formance of dry cupping. It consists of a glass bell, with a globular and hollow 
top of rubber (Fig. 50). The rubber bulb is emptied of air by squeezing, the 
glass bulb, the edges of which have been greased, is pushed upon the skin, and 
the compression is relaxed upon the rubber bulb. A partial vacuum is created, 
and an area of skin and subcutaneous tissue full of blood rises into the glass bell. 

Cupping can be easily performed by means of a tumbler. The edge of the 
glass is greased; a bit of blotting-paper wet with alcohol is placed in the bottom 
of the tumbler and lighted. After a brief period the glass is inverted and placed 
upon the skin, which has been dampened with warm water. As the air in the 
glass cools, the tissues rise into the partial vacuum. 

Wet Cups. — Wet cups draw blood, and the skin should be cleansed before 
they are applied. In wet cupping apply a cup for a moment, remove it, incise 



Cold in Treatment of Inflammation 93 

or puncture the skin, and replace the cup to draw the requisite amount of 
blood. Incisions may be made by an ordinary scalpel, a lancet, or a scarifi- 
cator, a cup being then applied. An excellent scarificator is shown in Fig. 
51. In this instrument concealed blades are thrown out by touching a spring. 
Baron Heurteloup devised an instrument (Fig. 52) in which the incision is 
made by a scarificator. The blood is drawn out by a pump, the tube being 
placed upon the cut area and the withdrawal of the piston creating a vacuum. 
This instrument is known as the "artificial leech." After scarification and 
the application of the cup, the partial vacuum draws blood into the cup; when 
the surface ceases to bleed, the cup is removed, and if further bleeding is 
thought desirable, the clots are wiped away and the cup is again applied, and 
after its removal warm fomentations are used (Cheyne and Burghard). Wet 
cupping is of value in pleuritis, pericarditis, and nephritis. 

Cutting off the Blood-supply. — Onderdonk, of New York, in 1813 
recommended ligation of the main artery of a limb for the cure of inflamma- 
tion in important structures supplied by the vessel. The procedure was 
warmly advocated by Campbell, of Georgia, for the treatment of gunshot 
wounds of joints. This plan of treatment is now not to be considered for a 
moment; antisepsis furnishes us with a safer and more certain plan. Yan- 
zetti, of Padua, advocates digital pressure to cut off the blood-supply to an 
inflamed part. 

Cold. — Cold is a very powerful and useful agent if used judiciously and 
applied at the proper time. It is valuable because of its reflex effect upon the 
vessels of the inflamed area rather than because of direct action upon the cells 
of a part. It should be used early in the case, before stasis occurs. It is not 
to be used in the later stages of inflammation, for it will then only aggravate 
the existing state; in fact, when there is considerable exudation cold does no 
good. 

Cold acts by constricting the vessels of a hyperemic area, thus lessening 
the amount of blood sent to the part, and preventing the evolution of the pro- 
cess into the stage of stasis and exudation. Further, it prevents the migra- 
tion of leukocytes, retards cell-proliferation, relieves pain and tension, and 
lowers temperature. If cold is too intense, if it is kept too long applied, if it 
is used late in an inflammation, if it is used upon an old or feeble patient, or 
if it is employed when there is much exudation or a condition of tissue strangu- 
lation, it does actual harm. It lessens the nutritive activity of cells, constricts 
the lymph-spaces and channels, increases existing stasis, and hence lowers the 
vitality of the tissues. If the parts are constricted, as in strangulated hernia, 
or if they are compressed by a large exudate, or fed by diseased blood-vessels, 
cold may cause gangrene. Xancrede, in his " Principles of Surgery," points 
out that in an inflammation stasis soon arises at the focus of the inflammation, 
and there is an area of stasis surrounded by a zone of hyperemia. Cold 
benefits the hyperemic zone but aggravates the stasis. Xancrede cautions us 
as follows: "Judgment is therefore requisite to decide whether the evil at 
the focus will not outweigh the good exerted at the periphery." * Xancrede 
further points out that cold must not be used intermittently; but if employed 
at all, must be continuously applied. If cold is applied intermittently, there 
will be a reaction whenever it is removed, and this reaction causes increased 

* " Principles of Surgery." 



94 Inflammation 

hyperemia. Hence, cold must be " continued in action to prevent reaction." 
If during the employment of cold the skin becomes purple and congested and 
the circulation feeble, at once discontinue the use of it, as its continuance will 
be dangerous. 

Cold may be used as wet cold or as dry cold. 

Wet Cold. — Wet cold is easily applied, but it is much more depressing than 
dry cold, is likely to produce discomfort, macerates the skin, and may lead 
to the formation of excoriations, etc. A part can be subjected to wet cold by 
the application of evaporating fluids or the use of a siphon. When wet cold 
is used inspect the part at frequent intervals, and discontinue the treatment 
if evidences of stasis become positive. Evaporating fluids are extensively 
employed. If such a fluid is used, never cover the part with a thick dressing. 
If this should be done, the fluid will not evaporate with sufficient rapidity to 
produce cold. A piece of thin muslin or flannel should be moistened with the 
fluid and laid upon the part, and be kept constantly moist by the application 
from time to time of small quantities of the liquid. Lead-water and laudanum 
is used extensively, and probably owes its chief value to the fact that it pro- 
duces cold on evaporation. Lead-water and laudanum is composed of 5j of 
laudanum, Sj of liquor plumbi subacetatis, and i pint of water. Liquor 
plumbi subacetatis dilutus may be used without laudanum. It is thought 
that the addition of laudanum tends to allay pain. A solution of ammonium 
chlorid may be used in the strength of 5j of the drug to 2 quarts of water. If 
ammonium chlorid is used for more than a short period of time, it is prone to 
cause the formation of blisters which are irritable and painful. Cheyne and 
Burghard use the following formula: h ounce of ammonium chlorid, 1 ounce 
of alcohol, and 7 ounces of water. Plain spring-water, iced wafer, or a mixture 
of alcohol and water may be used. The siphon is occasionally used. If 
there is a wound, the fluid must be aseptic or antiseptic. In conjunctivitis, 
cold is applied to the eye by means of linen or muslin soaked in iced water laid 
upon the closed lids, and frequently changed. 

To apply wet cold by means of a siphon, the part is covered with one layer 
of wet linen or muslin and is laid upon a rubber sheet folded like a trough and 
emptying into a bucket. A vessel filled with cold water is placed upon a 
higher level than the bed. A wet lamp-wick is now taken, one end is inserted 
into the water of the vessel, and the other end is laid upon the part. Capillary 
action and gravity combine to keep the part moist. A rubber tube may be 
used instead of a wick. If a tube is employed, tie it in a knot or clamp it so 
that the fluid is delivered drop by drop (Fig. 54). Ordinary water or iced 
water can be used. If the water be too warm, it can be reduced to about 45 F. 
by adding 1 part of alcohol to every 4 parts of water. A mixture of 5 parts 
of nitrate of potassium, 5 parts of chlorid of ammonium, and 16 parts of water 
produces great cold. 

Dry cold is more manageable and more generally useful than wet cold. 
It is applied by means of a rubber bag or a bladder filled with ground or finely 
cracked ice, several folds of flannel being first laid over the part. The flannel 
collects the moisture from the "sweating" bag and thus prevents maceration 
of the skin. Further, it saves the tissue from being subjected to too much 
direct cold and enables us to obtain the beneficial reflex effect. The ice-bag 
of India-rubber is widely used. We can venture to apply by means of the 



Cold in Treatment of Inflammation 



95 



ice-bag a greater degree of cold than it is proper to apply by the use of fluids, 
as dry cold is not so likely to induce gangrene as is moist cold. If there is 
much tenderness, the weight of an ice-bag causes pain, and it is best to suspend 
it from a frame, so that it lightly touches the part. The frame is the same as is 
used to keep the bedclothes from 
a fractured leg, and can be easily 
made from barrel hoops. Dur- 
ing the time an ice-bag is being 
used the part must be inspected 
at brief intervals to see that the 
circulation is not unduly de- 
pressed. The ice-bag is fre- 
quently used in joint-inflamma- 
tion, in intracerebral inflammation, in the earliest stage of appendicitis (see 
page 863), in epididymitis, and in acute myelitis. If a joint is sprained, the 
immediate application of an ice-bag is of great service. A part can be encircled 
with a rubber tube through which iced water is made to flow (Fig. 55). Even 
when this apparatus is used the part should first be wrapped in flannel. 
Leiter's tubes, which are tubes of lead made to fit various regions and which 




Fig- 53. — Ice-bag (W. E. Ashton). 




Fig. 54.— Siphon (Esmarch). 

carry a stream of cold water, can also be used. A piece of flannel must be 
placed between the tube and the skin. The temperature of these tubes can be 
lowered to any desired degree by lowering the temperature of the circulating 
fluid. Cheyne and Burghard caution us to use a fluid at a temperature not 
under 50 or 6o° F., to inspect the part every three or four hours, and not to 
employ the tubes longer than twenty-four hours. 



9 6 



Inflammation 




F'g- 55- — The Esmarch cooling coil. 



Heat is employed by some early in an inflammation. It is rarely beneficial 
at this stage, except when applied by a hot-air apparatus for the treatment of 

an injured joint. It is true 
that a degree of heat which 
does not actually destroy 
the tissues will contract the 
vessels as does cold; but 
this degree of heat will not 
be borne by the patient un- 
less but a limited portion 
of a superficial part is in- 
volved. 

Certain agents are 
suited to the stage of fully 
developed inflammation, 
when there is a great deal 
of swelling due to effusion 
and cell-proliferation. The 
indication in this stage is 
to abate swelling by pro- 
moting absorption. This 
is accomplished by (i) compression; (2) local use of astringents and sorbefa- 
cients; (3) the douche; (4) massage; and (5) heat. 

Compression. — Compression is especially useful in fully developed or in 
chronic inflammation, but it will do good even in the early stages. Compres- 
sion is of great usefulness; it supports the vessels and causes them to drink up 
effusion, and it strongly rouses the absorbents. This agent is valuable in 
most external inflammations with marked swelling and is particularly bene- 
ficial in chronic inflammation. In erysipelas of an extremity the part should 
be elevated and the extremity bandaged from the periphery to the body. In 
ulcers, especially those with hard and blue edges, the use of Martin's elastic 
bandage or of straps of adhesive plaster gives decided relief. In chronic in- 
flammation of a joint elastic compression is of great value. In epididymitis, 
after the acute stage, the testicle may be strapped with adhesive plaster. In 
lymphadenitis compression by a weight or by a bandage is very generally 
employed. In fractures compression not only antagonizes spasm, but often 
combats the swelling and pain of inflammation. Compression must be judici- 
ous; it must never be forcible, and it must not be applied to a limb without 
including the distal portion of the extremity (never, for instance, strongly 
compress the elbow without including the hand, nor the palm without band- 
aging the fingers). Injudicious compression causes severe pain and great 
edema, and may produce gangrene. 

Astringents and Sorbefacients. — Astringents may have direct value in 
inflammation of the skin, but it is not likely that they have any effect on deep- 
seated inflammation. When used in evaporating lotions in an earlier stage 
of inflammation the cold does good rather than the drug. Lead-water and 
laudanum is extensively employed and it is thought to somewhat allay in- 
flammatory pain. The mixture certainly gives comfort in cutaneous ery- 
sipelas. It is very doubtful if lead-water is of any service at any stage of a 
deep-seated inflammation or in any fully developed inflammation. If used 
after the first stage it must not be applied as an evaporating lotion, because 



The Douche 97 

cold will do harm. Pieces of lint are soaked in the fluid and placed upon the 
part, and a bandage is applied. The wet lint which has been placed upon 
the part is covered with oiled silk or a rubber dam before the bandage is 
applied. If used in the latter manner, the body-heat is retained in the part. 
If greater heat is required, a hot- water bag can be placed outside of the 
bandage. Lead-water is not used in treating wounds and hot lead-water 
should not be applied to a cutaneous inflammation. 

Tincture of iodin is astringent, sorbefacient, counterirritant, and anti- 
septic. It must not be used pure. For application to adults it should be 
diluted with an equal amount of alcohol, and for children with 3 parts of 
alcohol. In using iodin, paint it upon the part with a camel's-hair brush and 
fan it dry, applying one or more coats. The repeated application of iodin 
to the skin is of great benefit in inflammation of the glands, muscles, tendons, 
joints, and periosteum. Iodin is apt, after a time, to vesicate, and must not 
be used in full strength, because it is irritant. It is of special value in chronic 
inflammation. In deep-seated inflammation it acts as a counterirritant. 

Nitrate 0} silver is a non-irritating astringent of considerable value in 
inflammation of mucous membranes. It forms a protective coat of coagu- 
lated albumin, and is much used in treating the throat, mouth, and genital 
organs. In urethral inflammation a proteid compound of silver known as 
protargol may be used. 

Ichthyol is a drug of decided efficiency in reducing inflammatory swelling. 
It is usually employed in ointments, the strength being from 25 to 50 per cent. 
It is best exhibited with lanolin. When rubbed in over inflamed glands, 
joints, and lymphatic enlargements, it is of great value. In children a 25 per 
cent., and in adults a 50 per cent., ointment should be rubbed in thoroughly 
twice a day. In inflammatory skin-disease, synovitis, thecitis, frost-bite, 
bubo, chilblain, and in many other conditions, acute or chronic, the use of 
ichthyol is indicated. The odor of ichthyol is highly disagreeable, and when 
ordered for a refined person it had better be deodorized. For this purpose 
Hare uses oil of citronella, n^xx to 5j of ointment. 

Mercurials. — Blue ointment, pure or diluted to various strengths, is ex- 
tremely valuable. It is spread upon lint and kept applied over areas of fully 
developed inflammation. It is especially useful in acutely or chronically 
inflamed joints, glands, tendons, etc. Blue ointment is strongly irritant, and 
will soon blister or excoriate a tender skin. It is very beneficial in periostitis, 
and is employed largely in chronic inflammations. 

The Douche. — -The douche consists of a stream of water falling upon a 
part from a height. The water may be poured from a receptacle or may run 
through a tube, and may be either hot or cold. Alternating hot and cold 
streams are very popular in inflammations of joints and tendons, especially in 
chronic inflammation. This mode of application is known as the "Scotch 
douche." It restores the tone of the blood-vessels and plasma-channels and 
promotes the absorption of inflammatory exudate. If the part is very tender, 
the water should be squeezed upon it from sponges. In a sprain of the knee- 
joint, after a time, when thickening has occurred, pour upon the part daily, 
from a height, first a pitcherful of very hot water, then a pitcherful of very cold 
water; then use friction with a hand greased with cosmolin. Hot vagina) 
douches are generally employed in pelvic inflammations. 
7 



98 Inflammation 

Massage. — Massage is a procedure not frequently enough employed. 
It is very useful in some acute inflammations, though in these it must be gentle. 
It is of great service in the treatment of sprains of joints and fractures of bones. 
It is influential for good in chronic inflammations at the period when rest is 
abandoned. It acts by promoting the movements of tissue-fluids (blood, 
lymph, and areolar fluid), stimulating the absorbents, strengthening local 
nervous control, and thus improving nutrition. Passive motion in joints 
acts as massage. 

Heat. — Heat may be used continuously or intermittently, and may be 
either moist or dry. A considerable degree of heat will act like cold and 
contract the vessels. The degree necessary to cause vascular contraction 
would not destroy the tissue, but would produce discomfort, which discomfort 
would become unbearable during the continuance of the application. There- 
fore, heat is rarely used in the earliest stage of an acute inflammation. It is 
hard to state exactly when heat should be substituted for cold. Certainly 
when retardation and stasis are manifest it is to be preferred. Moderate heat 
should be used when inflammation is not very superficial. In a cutaneous in- 
flammation heat usually does harm, because it increases the congestion of an 
inflamed superficial part. In deep-seated inflammations heat to the surface 
acts as a revulsive or counterirritant. Thus a poultice to the chest may do 
good in the first stage of pneumonia, and cauterization of the skin near a joint 
may benefit an acute synovitis. The use of heat for purposes of counterirrita- 
tion will be discussed under the head of Counterirritants. A moderate 
degree of heat applied over a fully developed and not too superficial inflamed 
area dilates the vessels, especially the veins, of the skin and superficial tissues. 
Thus circulation is re-established in an area filled with stagnant blood or 
blood which is scarcely moving and the inflamed region is drained, fluid 
exudate is absorbed, tension is lessened, the lymph-spaces and vessels distend, 
and lymphatic absorption becomes active. The application of heat increases 
the ameboid activity of the leukocytes, phagocytes gather in great numbers 
and surround an area of infection, and those which have taken up bacteria or 
tissue debris hurry away.* Heat also, in all probability, causes antibodies to 
escape from the leukocytes and blood-serum. Heat notably lessens the pain 
of inflammation. It is often used purely to relieve pain. 

The forms 0} heat are — (1) fomentations; (2) poultices; (3) water-bath; 
and (4) dry heat. 

Fomentation is the application to the skin of a piece of flannel containing 
a hot liquid. A basin is warmed and over the top of the basin a towel is placed. 
A piece of flannel folded in two or three thicknesses is laid upon the towel and 
boiling water is poured upon it. By twisting the towel the water is squeezed 
out of the flannel. Great care must be taken to squeeze the water out of the 
flannel, otherwise the skin may be scalded. The hot flannel is laid upon the 
skin over the disordered part. A rubber dam larger than the flannel is placed 
over it, a mass of cotton is laid upon the rubber dam, and a bandage is applied. 
The fomentation must be changed within an hour unless a hot-water bag has 
been placed outside the bandage, in which case it need not be changed for 
two hours or more. The flannel which is dipped into the hot liquid is known as 
a " stupe." The turpentine stupe is made by wringing out the flannel as above 
*Nancrede, in '' Principles of Surgery." 



Poultice or Cataplasm 99 

and then putting upon it from 10 to 20 drops of turpentine. Instead of foment- 
ing the part, steam may be thrown upon it. Fomentations are used chiefly 
for their reflex influence over deep congestions or inflammations. The liquid 
of a fomentation may, if desired, contain corrosive sublimate, carbolic acid, 
or other agents. A fomentation containing an antiseptic is known as an 
antiseptic fomentation. An antiseptic fomentation, or, as it is often called, 
an antiseptic poultice, is made and applied as follows: Gauze is used instead 
of flannel, and is laid upon the towel over the basin as previously described. 
A very warm solution of corrosive sublimate (1 : 1000) is poured upon the 
gauze, the material is partly wrung out, placed upon the part, covered with a 
rubber dam, and upon it a hot-water bag is placed. Fomentations are very 
useful in relieving pain in any stage of an inflammation and act also as counter- 
irritants. Fomentations are used in preference to ordinary poultices if there 
is any probability of a surgical operation becoming necessary, because skin to 
which a poultice has been applied cannot be satisfactorily sterilized. The 
antiseptic fomentation is of great service in removing sloughs from foul wounds 
and ulcers. It is the only form of poultice which is admissible when the skin 
is broken. 

Poultice or Cataplasm. — A poultice is a soft mass applied to a part to bring 
heat and moisture to bear upon it. Poultices can be made of ground flaxseed, 
of slippery-elm bark, of arrowroot, starch, bread and milk, potatoes, turnips, 
etc. To make a flaxseed poultice, scald a spoon and a tin basin, put the flax- 
seed into the dry hot basin, and pour upon it boiling water in sufficient quan- 
tity to form a thick paste. The proper consistence is found when the mass 
would stick if it were thrown against a wall. It is now spread to the thickness 
of a quarter of an inch upon a piece of warm muslin, a free edge being left all 
around, the edges of the muslin are turned in, and the flaxseed is covered 
with a bit of gauze to prevent adhesion to the skin. The poultice should be 
placed upon the part and be covered outside with oiled silk, a rubber dam, or 
waxed paper. A mass of cotton is applied outside of the rubber and the poul- 
tice is held in place by a bandage or binder. It can be kept very warm for a 
considerable period by placing upon it a bag filled with hot water. If a hot- 
water bag is not employed, a poultice should be changed every two hours. 
Spongiopilin, when moistened with hot water, is a good substitute poultice. 
Lint soaked with hot water and covered with some impermeable material does 
very well. The fermented poultice, which was once popular for gangrenous 
ulcers, was made by sprinkling yeast upon an ordinary cataplasm. The 
charcoal poultice is made by stirring charcoal into the usual poultice-mass. 
A poultice containing opium is known as a "sedative" poultice. About gr. ij 
of opium to the ounce of poultice-mass may relieve pain. Flaxseed is a vege- 
table material, adheres to the skin, enters the mouths of glands and follicles, 
undergoes decay, and can be removed only with great difficulty. The prepa- 
ration of an antiseptic poultice or fomentation is described above. Poultices 
must not be kept on the part too long, as they will cause vesication, especially 
in adynamic conditions. If a poultice is causing vesication, remove it and 
do not replace it, or replace it after sprinkling the part and the poultice with 
powdered oxid of zinc. If suppuration exists or is seriously threatened, do 
not waste time by using poultices, but incise at once. Incision may pre- 
vent suppuration by relieving tension, affording drainage, and permitting the 



ioo Inflammation 

local use of antiseptics. If pus exists, it cannot be evacuated too soon. To 
use poultices and delay incision is often productive of irreparable harm. 
After incision of a purulent focus it is common practice to apply an antiseptic 
fomentation in order to draw quantities of leukocytes to the part and thus 
limit the spread of infection and stimulate granulation. 

Hot-water Bath. — The continuous hot bath is now rarely employed except 
in burns and cases of phagedena, when it often proves curative. In these 
cases an antiseptic agent may be dissolved in the water. Continuous immer- 
sion in a warm bath is regarded favorably by some surgeons for the treatment 
of sloughing wounds and large purulent areas. The immersion of a part 
from time to time in water as hot as can be tolerated is useful in fully developed 
and in chronic inflammation. Such immersion benefits an inflamed joint, 
lessening the pain, swelling, and stiffness. 

Dry heat is applied by a metallic object dipped in hot water and laid upon 
the part; by Leiter's tubes, through which hot water flows; by the hot-water 
bag or by the hot-air apparatus. Some surgeons use the hot-water bag in 
cases of mild appendicitis, in order to favor the formation of adhesions. The 
hot-water bag is often soothing and beneficial when laid upon an inflamed 
joint, or on the perineum or the hypogastric region in cystitis. A bag of hot 
sand, a hot brick, or a bottle or can of hot water may be used instead of the 
bag. The hot-air apparatus is of very great service in the treatment of in- 
flamed joints {vide dry hot-air apparatus). 

Treatment when Suppuration is Threatened. — When suppuration is threat- 
ened, ordinary hot fomentations or antiseptic fomentations must be used, 
and the part must be kept at rest. As previously explained, the flaxseed 
poultice is inadmissible. When suppuration is threatened, the use of heat 
causes the collection of multitudes of leukocytes, which tend to limit the area 
of infection and destroy bacteria. Even when suppuration is not prevented, 
heat aids in the rapid breaking down of the diseased tissue at the focus of 
the inflammation and causes hordes of leukocytes to gather and encompass 
the suppurating tissue, and these leukocytes prevent the spread of the in- 
fection. 

In most cases, when suppuration is obviously inevitable or seriously 
threatened, a free incision will be of greatest benefit. 

Irritants and Counterirritants in Inflammation. — Irritants attract 
an increased supply of blood to the part whereon they are applied, and are 
used for their local effects. Counterirritants are used to affect by reflex 
influence some distant part. In chronic inflammation irritants may do good 
by promoting the blood-supply, thus favoring the removal of exudates (lini- 
ment for rheumatism and synovitis, and nitrate of silver for ulcers). Counter- 
irritants are powerful pain-relievers when used over an inflamed structure; 
they bring blood to the surface and are thought by many writers to cause 
anemia of internal parts, the site and area of anemia depending on the site, 
the area, and the duration of the surface irritation. Some recent studies seem 
to indicate that counterirritation produces hyperemia of the superficial part, 
compensatory anemia of surrounding regions, and anemic edema of the sub- 
cutaneous tissue and muscles (W. Wecksberg, "Zeit. f. klin. Med.," Bd. 
xxxvii, H. 3 u. 4). Nancrede dissents from the statement that counterirritants 
cause anemia of internal parts; and he maintains that they irritate deeper parts 



Irritants and Counterirritants 101 

and cause more external blood to be taken to them. He claims that a blister 
applied to the chest produces a hvperemic area in the pleura, and refers to 
Furneaux Jordan's opinion that direct irritation to the surface over a joint 
adds to synovial hyperemia, and that consequently in joint-inflammation 
counterirritants should be applied above and below a joint, but not directly 
over it. As a matter of fact, we know clinically that powerful counterirritation 
directly over an inflamed superficial joint is occasionally followed by an aggra- 
vation of the trouble, and that in pericarditis blistering directly over the peri- 
cardium may, as pointed out by Brunton, make the condition worse. Coun- 
terirritants not only relieve pain in the earlier stages of inflammation, but they 
also promote absorption of exudate in the later stages, and are particularly 
valuable in chronic inflammations. Great benefit is obtained by blistering 
old thickened ulcers, and by painting the chest with iodin to relieve pleuritic 
effusion. Frictions, besides their pressure effects, act as counterirritants. 
Frictions may relieve skin pain, and are associated with the application of 
stimulating liniments in the treatment of stiff joints. A mustard plaster is a 
valuable counterirritant in an acute deeply seated inflammation. Tincture 
of iodin is extensively used in chronic inflammation. 

There is no more efficient method of relieving pleural effusion than by 
the application of a succession of blisters. Blister are also used in the treat- 
ment of inflamed joints, pericarditis, pneumonic consolidation of the lung, 
acute and chronic rheumatism, etc.; and are applied back of the ears or at the 
nape of the neck in congestive coma or meningitis. A blister can be produced 
in a few minutes by soaking a bit of lint in chloroform, and after applying it 
to the surface, covering it with oiled silk or with a watch-glass. Equal parts 
of lard and ammonia will blister in five minutes. It is easier to blister with 
cantharidal collodion or blistering paper. Before applying a blister, shave 
the part if it be hairy; then grease the plaster with olive oil and apply it. 
Blistering plaster is left in place six hours in the case of an adult, but only two 
hours in the case of an old person or a child ; the plaster is then removed, and 
if a blister has not formed, the part must be poulticed for a few hours. When 
a blister is obtained, open it with a needle which has been dipped in boiling 
water. If the surgeon wishes the blister to heal, it should be covered with a 
piece of lint smeared with cosmolin or with zinc ointment. If it is to be kept 
open for a time, cut away the stratum corneum and dress with cosmolin, each 
ounce of which contains six drops of nitric acid. 

Pustulation can be effected with tartar-emetic ointment or with Vienna 
paste. Tartar-emetic ointment was formerly used on the scalp in meningitis. 
Vienna paste consists of 5 parts of caustic potash and 6 parts of lime made into 
a paste with alcohol. It is applied for five minutes, and is then washed off 
with vinegar. 

The hot iron is the most powerful of counterirritants. It is chiefly used 
in chronic inflammation of joints, bone, and the spinal cord. The application 
is, of course, very painful, and it is best to give an anesthetic before using the 
cautery. A flat cautery iron may be used, or the round iron. The latter i> 
known as the button or Corrigan's cautery. The iron is used at a white heat. 
One area or several may be seared. The cautery is drawn lightly two or 
three times over each spot we wish to burn. The object is to destroy only the 
superficial layers of the skin. After the cauterization is completed, lint wet 



102 Inflammation 

with iced water is applied for several hours to allay pain, and then hot anti- 
septic fomentations are used until the slough separates. 

If we wish to prevent healing after separation of the slough, dress the sore 
with cosmolin, each ounce of which contains 6 drops of nitric acid. It is not 
wise to cauterize deeply directly over a superficial joint. 

Constitutional Treatment of Inflammation. — Certain remedies are 
used in inflammation for their general or constitutional effects; these remedies 
are — (i) general bleeding; (2) arterial sedatives; (3) cathartics; (4) diaphor- 
etics; (5) diuretics; (6) anodynes; (7) antipyretics; (8) emetics; (9) mercury 
and iodids; (10) stimulants; and (n) tonics. 

General Bleeding, Venesection, or Phlebotomy. — Venesection is suited 
to the early stages of an acute inflammation in a young and robust subject. 
The indication for its employment is increased arterial tension, as shown by a 
strong, full, rapid, and incompressible pulse in a vigorous young patient. 
General blood-letting diminishes blood-pressure and increases the speed of 
the blood-current, thus amends stasis, absorbs exudate, and washes adherent 
corpuscles from the vessel-wall; furthermore, it reduces the whole amount 
of body blood and thus forces a greater rapidity of circulation, decreases the 
amount of fibrin and albumin, lowers the temperature, arrests cell-prolifera- 
tion, and stops effusion. 

This procedure was in former days so highly esteemed that it settled into 
a routine formula to be applied to every condition from yellow fever to dislo- 
cation. The terrible mortality of the cholera epidemics from 1830 to 1835 
led practitioners to question the belief that bleeding was a general panacea, 
and from this doubt there was born in the next generation violent opposition 
to blood-letting in any disease. Like most reactions, opposition has gone too 
far, the pendulum of condemnation has swung beyond the line of truth and 
sense, and thus is universally neglected or broadly condemned a powerful and 
valuable resource. Many physicians of long experience have never seen a 
person bled; its performance is not demonstrated in most schools, and but 
few patients and families will permit it to be done. But when properly used 
it is occasionally beneficial. It is applicable, however, only to the young, 
strong, and robust, and not to the old, weak, or feeble. It is used for violent 
acute inflammations of important organs or tissues, and not for low inflam- 
mations or for slight affections of unimportant parts. It is used in the early, 
but not in the late, stages of an inflammation. It is used when the pulse is 
frequent, full, hard, and incompressible, but not when it is slow, small, soft, 
compressible, and irregular. It is used when the face is flushed, but not when 
it is pallid. It is not used in fat persons, drunkards, very nervous people, or 
the sufferers from adynamic, septic, or epidemic diseases. It is of value in 
some few cases of congestion of the lungs, pneumonitis, pleuritis, meningitis, 
prostatitis, cystitis, and other acute inflammatory conditions. It is particularly 
valuable when uremia exists or when there is distention of the right side of 
the heart. The method of bleeding is described on page 398. 

After bleeding, the patient should be put on arterial sedatives, diuretics, 
diaphoretics, anodynes, and, if necessary, purgatives. A favorite mixture of 
Prof. S. D. Gross was the antimonial and saline, gr. xl of Epsom salt, gr. -^ 
of tartar emetic, 2 drops of tincture of aconite, and ~jj of sweet spirits of niter, 
in enough ginger syrup and water to make §ss; given every four hours. 



Cathartics 103 

Arterial Sedatives. — Drugs of this character are of great use before stasis 
is pronounced; but if used after stasis is established they will increase it. If 
stasis exists it may be relieved by blood-letting, local or general, and then 
arterial sedatives can be given. Either local bleeding or venesection abolishes 
stasis and lowers tension, and arterial sedatives maintain the effect and hold 
the ground which is gained. The arterial sedatives employed are aconite, 
veratrum viride, gelsemium, and tartar emetic. These sedatives lessen the 
force and the frequency of the heart-beats, and thus slow and soften the pulse, 
and are suited to a robust person with an acute inflammation, but are not 
suited to a weak individual in an adynamic state. 

Aconite is given in small doses, never in large amounts. One drop of 
the tincture in a little water is given every half hour until its effect is manifest 
on the pulse, when it may be given every two or three hours. Large doses 
of aconite produce pronounced depression, and are dangerous. Aconite 
lowers the temperature, slows the pulse, and produces diaphoresis. 

Veratrum viride is a powerful agent to slow the pulse and to lower blood- 
pressure; it produces moisture of the skin, and often nausea. It is given in 
1 -drop doses of the tincture every half hour until its physiological effects are 
manifested, when the period between doses is extended to two or three hours. 
Ten drops of laudanum given a quarter of an hour before each dose of vera- 
trum viride will prevent nausea. 

Gelsemium is an arterial sedative highly approved by Bartholow. It is 
given in doses of 5 to 10 drops of the tincture every three or four hours. 

Tartar emetic lowers arterial tension and lessens the pulse-rate. This 
drug is not generally employed; if it is used with the greatest care it is no 
better than some other agents, and if it is not so used it will cause dangerous 
depression. The dose is from gr. oV to gr. T V in water every three hours 
until the physiological effects are manifest. 

Cathartics. — Purgation is of great value in inflammation. By it putrid 
material is removed from the intestine, fluid containing poisonous elements 
is drawn from the blood, and the liability to infection of the tissues is lessened. 
The administration of purgatives is, of course, not to be a routine procedure 
in inflammatory states. The bowels may be acting so freely that no cathartic 
is required. Treatment in an inflammation should be inaugurated, if 
constipation exists, by giving a cathartic. The tongue affords important 
indications as to the necessity for purgation. Castor oil can be given in cap- 
sules, or the juice of half a lemon is squeezed into a tumbler, 1 ounce of oil 
poured in, and the rest of the lemon is squeezed on top, thus making a not 
unpalatable mixture. Alo'in, podophyllum, the salines, and calomel in 5- 
or 10-grain doses, followed by a saline, have their advocates. In peritonitis 
the salines are of unquestionable value, a teaspoonful of Epsom salt and a 
teaspoonful of Rochelle salt being given hourly until a movement occurs. In 
the course of inflammation, from time to time, if there be constipation, a 
coated tongue, and foulness of the breath, there should be ordered gr. j of 
calomel with gr. xxiv of bicarbonate of sodium, made into twelve powders, 
one being given every hour; if the bowels are not moved by the time the 
powders are all taken, a saline should be given. If a violent purgative effect 
is desired, as in meningitis, croton oil or elaterium may be ordered. If con- 
stipation is persistent, give fluid extract of cascara sagrada daily (20 to 40 



104 Inflammation 

drops), or a pill at night containing gr. | of extract of belladonna, gr. \ of 
extract of nux vomica, gr. Yt of aloin, gr. \ of extract of physostigma, and gtt. 
\ of oil of cajuput. Enemas or clysters may be used in some cases. A very 
useful enema is composed of i%\ of oil of turpentine, fSiss of olive oil, fSss 
of mucilage of acacia, in f§x of water. Soapsuds and vinegar in equal parts 
make a serviceable clyster. A combination of oil of turpentine, castor oil, 
the yolk of an egg, and water can be used. Asafetida, gr. xxx to the yolk 
of one egg, makes a good enema to amend flatulence. 

Diaphoretics. — These agents are very useful. A profuse sweat removes 
much toxic material from the blood and in the beginning of an acute inflam- 
mation, such as tonsillitis, may abort the disease. Dover's powder is commonly 
used, but pilocarpin is preferred by some. Camphor in doses of from 5 to 
10 grains is diaphoretic, and so are antimony and ipecac. Acetate and 
citrate of ammonium, opium, alcohol, hot drinks, heat to the surface (baths, 
hot bricks, hot- water bags), serpentaria, and guaiac are diaphoretic agents. 

Diuretics. — Diuretics are useful in fevers when the urine is scanty and 
high-colored, and are valuable aids in removing serous effusions and other 
exudates. Among the diuretics may be mentioned calomel in repeated large 
doses, cocain, alcohol, digitalis, the nitrites, squill, turpentine, copaiba, and 
cantharides. The liquor potassae and the acetate of potassium are the best 
agents to increase the solids in the urine. The liquor potassii citratis in 
doses of foj to foiv is efficient. Large draughts of water wash out the kidneys. 
If the heart is weak, citrate of caffein is a good stimulant diuretic, and hot 
coffee is very serviceable in promoting the secretion of urine. The injection 
of hot salt solution into the rectum and under the skin favors diuresis, and 
the intravenous infusion of salt solution is a very powerful diuretic. The 
application of heat to the loins promotes the secretion of urine. Sodio- 
theobromin salicylate (diuretin) is an uncertain but often valuable diuretic, 
in doses of gr. x every two or three hours. 

Anodynes and Hypnotics. — Drugs may be required to allay pain or 
procure sleep. Dover's powder, besides being diaphoretic, is anodyne. 
Opium acts well after bleeding or purgation. If it causes nausea, it should be 
preceded one hour by the administration of gr. xxx of bromid of potassium. 
Opium is used by the mouth, by the rectum, or hypodermatically. It is used 
when there is pain, but its use is not to be long persisted in if it can be avoided. 
It is given in doses measured purely by the necessities of the case. If opium 
disagrees, try the combination of morphin with atropin. After an operation 
antipyrin or phenacetin will often quiet pain and secure sleep. When a person 
feels "so tired he can't sleep," alcohol in the form of whiskey or brandy must 
be given. Sleeplessness not due to pain is met by chloral, trional, the bromids, 
or sulphonal. Chloral is dangerous in conditions of weak heart or exhaustion. 
Bromids must be given in large doses to be efficient. Sulphonal must be given 
about four or five hours before sleep is expected, in doses of from gr. x to gr. xx 
in hot milk or hot mint-water. Trional is safe and very satisfactory. It is 
given in doses of gr. xv to gr. xxv in hot water. 

Antipyretics. — Arterial sedatives, diaphoretics, and purgatives lower 
temperature, and have previously been alluded to (page 103). There are two 
great classes of febrifuges — those which lessen heat-production and those 
which increase heat-elimination. In the first group we find quinin, salicylic 



Mercury and the Iodids 105 

acid and the salicylates, kairin, alcohol, antimony, aconite, digitalis, cupping, 
and bleeding. In the second group we find alcohol, nitrous ether, antipyrin, 
acetanilid, phenacetin, opium, ipecac, cold to the surface, and cold drinks. 
In surgical inflammations it is rarely necessary to employ heroic means to 
lower temperature. The use of such an agent as antipyrin is contraindicated 
in the weak and adynamic, and it is never to be thought of as a means of lower- 
ing temperature unless the latter goes above 103 F. Quinin, in doses of 
gr. xx to gr. xxx given at 4 p. M., may prevent an evening rise; salol or salicin 
can be given during the day. Inunctions of 30 minims of guaiacol lower the 
temperature in tuberculous conditions and in septic fevers. These inunctions 
are made upon the abdomen, and often produce surprising results. Dujardin- 
Beaumetz maintained that fever is a condition in which the animal organism 
is endeavoring to oxidize and render inert certain poisonous material, and 
that antipvretic drugs lessen oxidation and actually make the patient worse. 
This view is in accordance with the experience of a number of surgeons. It 
is a suggestive fact that bacteria are said to multiply more rapidly when kept 
at about the normal body-temperature than when kept at fever heat (102 F., 
or more). The mere discomfort of fever may be much mitigated by anti- 
pvretic drugs, but the fever process is not benefited by them. 

Emetics. — Emetics may do good when the patient suffers from a parched, 
coated tongue, a dry and hot skin, nausea, and gastric oppression, but it is 
very rarely in these days that we employ them. There can be used 5j of alum 
in molasses, gr. xx of sulphate of zinc, or a tablespoonful of mustard and a 
teaspoonful of salt given in warm water and followed by large draughts of 
warm water. Ipecac in a dose of gr. xx can be employed. The emetic dose 
of tartar emetic is gr. ij, but it is too depressant a drug to trifle with. The 
sulphuret of antimony in doses of from 1 to 5 grains is safe. Apomorphin 
hypodermatically, in a dose of from gr. -^g- to gr. J, will act in five minutes. 
Emetics are valuable in inflammatory conditions of the air-passages, but their 
use is contraindicated in diseases of the heart, brain, and bowels, in hernia, 
in dislocations, in fractures, and in aneurysms. 

Mercury and the Iodids. — Mercury is an alterative — that is, an agent 
which favorably affects body nutrition without causing any recognizable 
change in the fluids or the solids of the body. Mercury lessens blood plas- 
ticity, hinders the exudation of liquor sanguinis — thus furnishing less food to 
the cells in the perivascular tissues — and retards cell-proliferation. Further, 
by a stimulant action on the absorbents it promotes the breaking up of an 
existing inflammatory exudation, and hence limits damage from excess of 
new formation. The time at which mercury is best given is when violent 
symptoms have abated, the guides being a reduced temperature and a moist 
skin. Mercury is often given in conjunction with the local use of sorbefacients 
(ichthyol, or mercurial ointment). When possible, the administration of 
mercury is associated with compression of the inflamed part. It is sometimes 
given until the gums are slightly touched, but it is not given to the point 
of salivation. When the breath becomes offensive and the gums tender on 
snapping the teeth, or when griping and diarrhea begin, the dose should be 
reduced, or the drug should be stopped (see Ptyalism). In iritis mercury is 
used to get rid of the plastic effusion which is causing pupillary fixation and 
opacity. In keratitis the gums should be touched slightly. In orchitis, after 



106 Inflammation 

the subsidence of the acute symptoms, mercury should be employed. In 
pericarditis, meningitis, and in many chronic and lingering, and in all 
syphilitic inflammations, this drug can be used. 

Some persons will be salivated with very minute doses of mercury, either 
because of idiosyncrasy or previous saturation. Others can take enormous 
doses without any appreciable constitutional effect. The action of mercurials 
can be favored by a combination with ipecac or with tartar emetic. 

In giving mercury, if a prompt effect is desired, give gr. iij of calomel every 
three hours until a metallic taste is noted in the mouth. If the case is not so 
urgent, gray powder is a good combination. Children are given calomel and 
sugar or mercury and chalk. If it is desired to give the drug for some time, 
corrosive sublimate is a suitable form, and small doses will actually increase 
the number of red blood-corpuscles. Corrosive sublimate is to be given alone 
or combined only with iodid of potassium. The green iodid of mercury is a 
drug suitable for prolonged administration. In the prolonged use of mercury 
it will often be necessary to give at the same time a little opium to prevent 
diarrhea and griping. A rapid effect can be obtained by rubbing daily with 
a gloved hand 5j of the oleate of mercury or 5ss of the ointment into the 
groins, the axillae, or the inside of the thighs. Suppositories of mercurial 
ointment induce rapid ptyalism. Hypodermatic injections of corrosive sub- 
limate or gray oil may be used, and must be thrown deeply into the muscles 
of the buttock or back. Old people, those who are exhausted, anemic, and 
broken down, and the tuberculous bear mercury badly. If it be given to them 
at all, it must only be in small amounts and for a brief time. 

Alkaline iodids are useful in removing the products of inflammation; they 
can be given for a long time, and admirably supplement mercurials. Iodid 
of potassium can be prescribed in combination with corrosive sublimate as 
follows : 

R. Hydrarg. chlor. corros., gr. ij ; 

Potass, iodidi, 3 V et 9J ! 

Syr. sarsaparillse comp., q. s. ad f^viij. — M. 

Sig. — f^ij, in water, after meals. 

Iodid of potassium, well diluted, is given on a full stomach; it is never 
given concentrated or before meals. A convenient mode of administration 
is to procure a concentrated solution of the iodid of potassium, remembering 
that every drop equals about gr. j of the drug, and give as many drops as may 
be desired in half a glass of water after meals. If the medicine disagrees, add 
to each dose, after it is put in water, 5j of the aromatic spirit of ammonia. 
Extract of licorice is a good vehicle for the iodid. If the mixture in water 
disagrees, the drug should be given in milk. Capsules are satisfactory, but 
a drink of water should be taken just before and again just after taking a 
capsule, to protect the stomach from the concentrated drug. Iodid of sodium 
may agree when iodid of potassium does not. When the iodids disagree they 
produce iodism. The first indications of iodism are a bad taste in the mouth, 
running of the eyes and nose, and sneezing, followed by a feeling of exhaustion, 
absolute loss of appetite, nausea, tremor, and skin eruptions (acne, hemor- 
rhages, blebs, hydroa, etc.). If iodism occurs, stop the drug and give the 
patient Fowler's solution in increasing doses, laxatives, diuretic waters, and 
also nutritious food, and stimulants if depression is great. Sometimes bella- 
donna does good in obstinate cutaneous disorders induced by the iodids. 



Antiphlogistic Regimen 107 

Remedies Directed Against Special Morbid States. — If inflammation 
is associated with rheumatism, gout, scurvy, syphilis, tuberculosis, or any 
other constitutional disease or predisposition, appropriate treatment should be 
instituted to control the disease or combat the predisposition, and at the same 
time the area of inflammation should be locally treated. Syphilis is treated by 
the internal use of mercury; in some cases the iodids are also given; scurvy, by 
vegetable juices and potash salts ; rheumatism, by the alkalies or salicylates; gout, 
by colchicum or piperazin; tuberculosis, by the fats, tonics, and open-air life. 

Stimulants. — The chief stimulants used are hot black coffee by the stomach 
or bowel; hot normal salt solution by the bowel, beneath the skin, or in a vein, 
alcohol by the mouth or rectum; and strychnin or atropin hypodermatically. 
The use of alcoholic stimulants is called for by conditions rather than by 
diseases, being indicated by the state of the patient rather than by the 
name of the malady. For a brief acute inflammation in a robust young 
person alcohol is not needed; but all who are weak or exhausted, be they 
young or old, all who are aged, those who are accustomed to alcoholic 
beverages, those who have high temperatures or failure of circulation, and 
those who labor under septic inflammations or adynamic processes require 
alcohol, and it should be given with a free hand. In an acute malady, a feeble, 
compressible, rapid, or irregular pulse, and great weakness of the first sound 
of the heart are indications that alcohol is required. Low, muttering delirium 
is a strong indication for stimulation. There is no dose of alcohol for these 
states ; it is given for its effect. Two ounces of brandy or whiskey may be needed 
in a day, or perhaps 20 ounces. If the breath of the patient smells strongly 
of the alcohol, he is getting too much. If delirium increases after each dose, 
alcohol is doing harm. Alcohol is contraindicated in acute meningitis. In 
acute illness use whiskey, brandy, champagne, or alcohol and water. During 
convalescence there may be used a little port, claret, or sherry wine, or malt 
liquor. These agents will promote appetite, digestion, and sleep. 

Strychnin is a very valuable stimulant. It can be given in doses of gr. \ 
to gr. 2*5- three times a day, but after a few days seems to lose its effect. 

Atropin is one of the best remedies for exhaustion of the vasomotor sys- 
tem. The dose is gr. j^ hypodermatically. 

Tonics. — The use of tonics is indicated during convalescence from acute 
and throughout the course of chronic inflammations. There may be used 
iron, quinin, and strychnin in the form of elixir; iron alone, as in the tincture 
of the chlorid; quinin in tonic doses (gr. vj to gr. viij daily); or Fowler's solu- 
tion of arsenic. An excellent pill consists of — 

1$. Acid, arsenos. , gr. j ; 

Strychnini, gr. ss, 

Quinini, gr. xlviij ; 

Ferri redact., gr. vj. — M. 

Ft. in pil. No. xxiv. 

Sig. — One after each meal. 

Bitter tonics before meals improve the appetite. One of the best of tonics is 
tincture of nux vomica in gradually increasing doses. 

Antiphlogistic Regimen. — This term comprises the necessary directions 
relating to diet, ventilation, cleanliness, etc. 

Diet. — When, in the early stages of an acute inflammation, the patient 



108 Inflammation 

cannot eat, there must be administered a cathartic before food is given. 
Nausea is combated with calomel and soda, drop-doses of a 6 per cent, solu- 
tion of cocain, iced champagne, iced brandy, chloroform-water, hot water, 
cracked ice, or the application of counterirritation to the epigastric region. 
When the process is depressive from the start, and in any case after the earliest 
stage, feeding is of vital moment. The great tissue-waste calls for large 
quantities of nutritive material, but the impaired digestion demands that the 
food shall be easily assimilable; hence it is taken in liquid form, small quan- 
tities being frequently given. Milk contains all the elements required by the 
body, and is the food of foods. If it disagrees, it should be boiled and mixed 
with lime-water, or to each dose an equal amount of Vichy or soda-water may 
be added. Peptonized milk is a valuable agent. One part of milk, 2 parts 
of cream, and 2 parts of lime-water make a nutritious and digestible mixture. 
Milk punch is largely used. Whey may be used when plain milk cannot be 
taken. Eggs are highly nutritious, but are apt to disturb the stomach; they 
may be given as egg-nog, or simply soft-boiled, or the yolk can be beaten up 
in a cup of tea. When considerable nausea exists, the yolk of an egg may 
be added to oj of lemon-juice and 5ij of sugar, the glass being filled with car- 
bonated water. Beef tea is certainly a stimulant, but its food powers are 
questionable. It is prepared by cutting up one pound of lean beef, adding 
to it a quart of water, and then simmering, but not boiling, down to a pint, 
finally filtering and skimming the liquid. The dose is a wineglassful seasoned 
to taste. Meat-juice, obtained by squeezing partly cooked meat with a lemon 
squeezer, is extremely nutritious. Liquid-beef peptonoids are both agreeable 
and nutritious; they are given in doses of §ss to 5j. Clam-juice is palatable 
and digestible. When nothing else will stay on the stomach koumiss will 
often be retained. This fermented milk is nutritious, stimulant, and very 
useful. Coffee is a valuable stimulant in febrile conditions. If the stomach 
retains no food, the patient must be fed entirely by the rectum. If the stomach 
rejects most of the food swallowed, mouth feeding must be supplemented by 
nutritive rectal enemata. When the sufferer feels able to eat a little, any good 
soup, strained and skimmed, should be ordered. As the patient gets better 
he may be fed on sweetbreads, chops, oysters, etc., until he gradually 
reaches ordinary diet. 

The temperature should be taken at regular intervals, and the condition of 
the gastro-intestinal tract should be observed. The urine must be examined 
at intervals, and the daily amount passed must be known. If insufficient 
urine is being passed, increase the amount of fluid, particularly of water, given 
by the mouth. If the urine is scanty and the patient is nauseated by drinking 
water, give enemata of hot saline fluid or employ hypodermoclysis. The 
pulse and heart must be frequently observed, and cardiac weakness must be 
combated by suitable stimulants. 

Ventilation and Cleanliness. — The ventilation of the apartment is of the 
greatest importance. Every day the windows should be opened widely for a 
time, the patient, of course, being protected. When the windows are open 
the air of a room can be quickly changed by swinging the door to and fro. A 
constant access of fresh air must be secured, and the temperature kept as near 
as possible to 68° F. The sick man must be cleaned and be sponged off with 
alcohol and water every day if high fever exists. It is important that the bed- 



Treatment of Chronic Inflammation 109 

clothing be clean and that the sheet be unwrinkled, as otherwise bed-sores 
may form. 

Treatment of Chronic Inflammation. — The subject of chronic inflam- 
mation has been referred to previously. The local treatment comprises rest, 
relaxation, elevation, counterirritation, massage, passive movements, the 
douche, the application of sorbefacients, the use of compression, incision, and 
perhaps, certain special methods as the induction of passive hyperemia by 
Bier's method (page 228) or baking the part in a hot-air oven. The patient 
must be placed under proper hygienic and climatic conditions; the diet must be 
judiciously regulated; drugs are given symptomatically or to combat some 
constitutional tendency or disease (see articles upon special regions and 
diseases). 



no Repair 



IV. REPAIR. 

When a tissue is damaged, it reacts to the injury and Nature attempts to 
effect repair. It is held by many that inflammation is a destructive process 
and repair is a constructive process; that repair is constantly effected in an 
aseptic wound without many of the evidences of inflammation; that repair 
does not proceed from inflammation, but is retarded or prevented if inflam- 
mation occurs. As before stated, we agree with Adami, that inflammation 
is reaction to injury and the effort of Nature to repair the injury. As 
Adami points out, the attempt to repair may fail, the reaction to injury being 
excessive or not powerful enough; but even should the attempt fail, the 
conservative intention exists. " What is the development of cicatricial tissue 
but an attempt at repair? What other meaning can be ascribed to the 
increased bactericidal power of the inflammatory exudate as compared with 
that of ordinary lymph and blood-serum ? Why do leukocytes accumulate in 
a region of injury ? Why do some of them incorporate bacteria and irritant 
particles, and others bring about the destruction of these without necessarily 
ingesting them ? All these are means whereby irritants are antagonized or 
removed, and reparation and return to the normal sought after." * 

Repair is favored by good general health, asepsis of the wound, coaptation of 
wound edges, and rest. It is retarded or prevented by infection, gaping of the 
wound, frequent or forcible motion, and impairment of the general health. 

Albuminuria and diabetes particularly obstruct repair. R. T. Morris 
points out that sugar in the blood is hygroscopic, removes water from the 
tissues, and thus obstructs repair; and also that the wound fluids contain 
sugar and are good culture-media ("Med. News," June 29, 1901). 

Healing by First Intention. — A wound may heal by "first inten- 
tion." This mode of healing, which is known as "primary union," occurs 
without suppuration, and is observed in the healing of an aseptic wound. If 
infection occurs, primary union will not take place. The phrase "by first 
intention" comes down to us from the past. It was properly thought that 
Nature intends to repair a wound, and first intention signifies the first or 
most desirable way to be wished for. In a small aseptic incision, in which no 
considerable vessels are cut, repair will take place very rapidly after the edges 
have been approximated and the wound dressed. In fact, the wound edges 
may be firmly held together in twenty-four hours. In such a wound a small 
amount of blood flows from the capillaries between the edges of the wound, 
and this blood clots. A trivial amount of exudation and some few migrated 
corpuscles pass into the clot and into the tissues. The fixed connective-tissue 
cells and the endothelial cells of the vessels multiply, and form epithelioid 
cells, known as fibroblasts. The fibroblasts eat up many of the leukocytes 
and multiply, so that the new cells from one side of the wound finally interlace 
with the new cells from the other side. Nearby capillaries become irregular 
in outline; at certain points bulging occurs, and at these points new capillaries 
develop, extend into the mass of fibroblasts, and join new capillaries of the 
opposite side. The reparative material is now said to be organized; it has 

* Adami, in Allbutt's "System of Medicine." 



Healing by First Intention in 

become granulation tissue. The fibroblasts become spindle-shaped and 
develop into interlacing fibers (Fig. 56). The tissue is now fibrous tissue; 
it contracts strongly, and finally most of the capillaries are obliterated by 
pressure. In such a slight wound the reaction to injury is chiefly noted in the 
cells of the part, and the vessels and leukocytes play but a small part in repair. 
The exudation is so scanty that there is practically no swelling unless some 
arises from venous obstruction. The vessels are so slightly affected that there 
is no redness. The final step in healing is contraction of the fibrous tissue and 
the covering of the surface with epithelium, which springs from the epithelial 
cells upon the edges. This final process is called ''cicatrization," and con- 
sists in the formation from fibroblasts of new 

fibrous tissue and the contraction of the new v . : -.-0'/r., '.': ''.'T' : " '"'^ 

tissue. The "immediate union" of some ^'" •■' -. < '; / 

writers never occurs. This term means the ^ ■■-";- -. . • - / 

union of microscopical parts to their counter- „'; <■ ;.- ' 

parts without any effort at repair. A first '-,■'.',•-• 

union is effected always by clotted blood and _^-- : i^ ' • .. --■' . c /°'^ 

coagulated exudate, next by proliferating cells. "^ : .#'•'•>- X f 

and finally by fibrous tissue. A wound heahng Fig - 6 _ Cells dev eioping into 
bv first intention exhibits no evidence of inflam- fibers (Bennett), 

mation. There is some slight tenderness, but 

no actual pain. A certain amount of swelling arises because of exudation 
of fluid from the blood, and the coagulation of this fluid makes the wound 
edges hard. Venous obstruction leads in some cases to a considerable fluid 
swelling. A wound may heal by first intention even if some bacteria are 
present, if the part has a good blood-supply and the patient is in good health. 
Active leukocytes and germicidal blood-serum may prevent infection. In 
a more extensive incised wound many vessels are cut. After oozing ceases 
the vessels are closed by clots continuous with the clot between the sides of 
the wound. An exudation of plasma from the blood-vessels and of lymph 
from the lymph-spaces takes place. Leukocytes in great numbers invade 
the wound edges and the exudate, and the exudate clots. Thus, an infection 
mav be surrounded and limited. This mass of blood-clot, plasma-clot, and 
leukocytes used to be known as " coagulable lymph." The leukocytes actively 
eat up the clot, and by the end of the third day occupy the space formerly 
occupied by the clot. The fixed connective-tissue cells and endothelial cells 
multiply and grow into the mass of leukocytes, eating up many of the leuko- 
cytes, and finally join the fibroblasts of the other side of the wound. Some 
leukocytes enter into the lymph-spaces. New capillaries form from the capil- 
laries at the wound margins. By the end of the first week the fibroblasts 
begin to assume various outlines, sending out poles or branches or becoming 
spindle-shaped. These spindle-shaped cells become fibers, and the fibers of 
the new tissue interlace and strongly contract. Thus the edges are pulled 
firmly together. Finally new epithelium derived from epithelium at the edges 
forms and grows over the wound (Figs. 57-59), and exhibits the stages of 
repair in healing by first intention. In order to obtain primary union the 
surgeon must cleanse the wound and must be thoroughly aseptic; bleeding 
must be carefully arrested; the parts are accurately coaptated by sutures; 
aseptic or antiseptic dressings are applied, and special care is taken to secure 
rest. In a large wound special methods to secure drainage are required. In 



112 



Repair 



a small wound drainage is obtained between the stitches. The use of irritant 
germicides in a wound greatly increases the amount of discharge and renders 
drainage necessary in even a comparatively small wound for the first twenty- 




— ~ ^> _sre 



--o - oj. 


d 


■ O ' ° -0' 

•£> 





<oS 



Fig. 59- 
Figs- 57~59-— Healing by first intention (after Pick): a, Skin; b, fibroblasts; c, d, e, capillaries. 
Fig. 57, Clot in the vessels continuous with clot between the edges of the wound. Fig. 58, Migration 
of leukocytes into the perivascular tissues and into the clot between the edges of the wound. Fig. 59, 
Formation of new capillaries. 



four hours. During the first twenty-four hours after a large wound begins to 
heal by first intention the discharge of bloody serum is most plentiful, but after 
this period it becomes very scanty and soon ceases entirely, and can be much 



Healing by Second Intention 113 

diminished in quantity in the first day by the application of pressure. Warren 
says that after a hip-joint amputation over a pint of bloody serum flows out 
during the first twenty-four hours. In an aseptic wound, as a rule, one-half 
of the stitches are removed on the sixth or seventh day and the remainder on the 
eighth day, but for two weeks more the wound should be rested and supported, 
as the new tissue is not very resistant to infection. Aseptic fever always arises 
when much exudation is poured out and not quickly and perfectly drained. 
Aseptic fever is due to the absorption of aseptic pyrogenous material (page 
124). If an incised wound becomes infected, the pyogenic organisms destroy 
the bond of union which is forming between the wound edges by liquefying 
the intercellular substance. As a consequence, the wound edges are widely 
separated by pus. 

What used to be known as " healing by blood-clot" is healing by first in- 
tention. If there is a considerable gap between the edges of an aseptic wound, 
and the gap is filled with a blood-clot, healing goes on in the same manner as 
when the gap is narrow, although more corpuscles, more exudate, and more 
fibroblasts are required to effect repair. 

Healing by Second Intention.— Healing of a wound in which there is a 
large cavity in the tissue or in which the edges have gaped apart is known as 
healing by granulation, or healing by " second intention." It is called healing 
by granulation because the granulations (areas of vascularizedembryonic tissue) 
are visible. It is effected in the same manner as healing by " first intention," 
the processes in the two cases being practically identical if pus is absent. As 
a matter of fact, in healing by granulation there is usually wound infection. 
As a result of infection intercellular substance is peptonized, many reparative 
cells are cast off, and repair can be effected only after the formation of enormous 
numbers of fibroblasts and the expenditure of considerable time. It requires 
much longer for an infected wound to heal than for an incised wound to be re- 
paired, and an infected wound can heal only by granulation. A short time 
after the infliction of a wound the oozing ceases because thrombi form in the 
vessels and some clot gathers in tissue-gaps and interstices. Exudation begins 
and leukocytes migrate into the exudate and into the walls of the wound. In 
an hour or two the surface of the wound becomes distinctly glazed or glistening, 
because of the formation and coagulation of fibrin. The exudation is at first 
thin and red, and it becomes so profuse as to wash away the discolored fibrin 
coat. In a few days the discharge usually becomes purulent. The connec- 
tive-tissue cells, especially the endothelial cells of the vessels, proliferate and 
form fibroblasts, and the fibroblasts multiply to close the wound. From ad- 
jacent capillaries new capillaries form. This formation takes place as follows: 
A portion of a capillary thickens and a whip-like process comes off from the 
thickened part. This process fuses with a second filament budded from an- 
other or from the same capillary, or runs straight out as a terminal vessel. The 
filaments after a time are hollowed out from within, protoplasmic tubes are 
formed, and endothelial cells develop from the protoplasm. In some cases a 
tubular prolongation comes off from a capillar}- directly. Figs. 59 and 60 show 
the formation of a capillary. In a wound healing by granulation these newly- 
formed capillaries run among the fibroblasts, and some of them run perpen- 
dicularly to the surface, or a loop forms and reaches the surface. The surface 
of a granulating wound is covered with migrated leukocvtes, and directlv under 
8 



ii4 



Repair 



these are fibroblasts covering the new vascular strings or loops. Vascular 
strings or loops coated with fibroblasts are called granulations (Fig. 62 shows 
a granulating surface). When the discharge becomes purulent, many leuko- 
cytes and fibroblasts are destroyed, inflammation increases, exudation be- 
comes profuse, and cellular multiplication widespread and rapid in order to 




Fig. 60. — Development of a blood-vessel in mesentery of an embryo (Warren). 



k 



make up for the cells lost by microbic action. Gradually the gap is filled. As 
it is being filled the older fibroblasts in the deeper layers of the edges and base 
of the wound are converted into cicatricial, fibrous, or scar tissue. (Fig. 61.) 
As the granulations rise to a higher level at the surface the area of fibrous tissue 

becomes broader at the base 
and margins, and this young 
fibrous tissue contracts. By 
contracting it draws the edges 
of the wound nearer together 
and thus lessens the area of the 
surface which must be covered 
with epithelium. When the 
granulations reach the level of 
the cutaneous surface the epithe- 
lial cells at the margin of the. 
wound proliferate, and young 
epithelial cells, constituting a 
bluish or opalescent film, grow 
over the granulations. Epithelium comes only from epithelium. Granula- 
tions are never converted into epithelium. The epithelial covering comes only 
from the epithelium at the wound margins, unless there be epithelial remains 









Fig. 61. — Cicatricial tissue ; X 670 ( Fowler). 




Cicatrices or Scars 115 

in the wound; for instance, an undestroyed papilla, sweat-duct, or hair follicle. 
The process of covering the surface with epithelium is known as epidermization. 
The epidermization of a large area always consumes considerable time and 
sometimes Nature fails to accomplish it. In such cases skin-grafting is em- 
ployed (</. v.): Before, during, and for a time after epidermization the fibrous 
tissue of the walls and base of the wound contracts. Thus the wound margins 
are pulled and held nearer together, the gap to be bridged is diminished in size, 
the danger of tearing apart of the epithelial coat is lessened, many capillaries 
are destroyed by pressure, and the scar becomes firm, white, and puckered. 
Cicatrization consists in the conversion of immature connective tissue into 
mature fibrous tissue and in the con- 
traction of the new fibrous tissue. If 
infection is severe, destruction will ex- 
ceed repair and healing will not occur. 
In such a case there is coagulation necrosis 
of granulation tissue, and the wound be- 
comes covered with tissue remains (aplas- 
tic lvmph). If granulations rise above 
the cutaneous level, healing will not take Fig " ' - Blood ;^sei s in granulation 

' ° (Gross). 

place, because the epithelium cannot then 

grow over the raw surface. A wound in this condition is said to possess ex- 
uberant granulations, or proud flesh. In some cases the granulations are pale 
from insufficient blood-supply, and in others edematous horn venous congestion. 
Contraction of the fibrous tissue may be insufficient because there is adhesion 
to deep unyielding fascia or to periosteum. Excessive contraction is frequent 
after burns, often produces terrible deformity. The scars or cicatrices of 
burns contain much elastic tissue. Infected wounds and ulcers heal by second 
intention. 

Healing by Third Intention. — This consists in the union of two granu- 
lating surfaces, the granulations of one side fusing with the granulations of 
the other side. It is seen in the union of collapsed abscess-walls. The sur- 
geon occasionally seeks to obtain union of a wound several days old by third 
intention by approximating two granulating surfaces. If the surfaces are 
aseptic, he will often succeed. The process follows what is known as secon- 
dary suturing. It is not unusual to pack a wound with iodoform gauze to 
control oozing. When this is done it is customary to pass the sutures, but 
not to tie them. After a few days the gauze is removed and the sutures are 
tied. This plan renders healing much more rapid than would be possible 
by the process of healing by second intention. 

Cicatrices or Scars. — The newly-formed connective tissue which con- 
stitutes a scar will be present in large amount if more granulations were found 
than were really necessary for repair of if a considerable defect was repaired. 

A recent scar contains fibrous tissue, many fibroblasts, and numerous 
blood-vessels but no nerves, lymphatics or elastic fibers. The skin above 
recent scars is usually red because of the numerous vessels beneath it and the 
layer of epidermis is well developed. In old scars fibroblasts have disappeared 
and fibrous tissue really constitutes the cicatrix. Some blood-vessels disappear 
and the diameters of those remaining are much reduced. These vascular chanu r * - 
result from contraction of the cicatrix. Delicate elastic fibers appear in old 



n6 Repair 

scars. They appear at the end of the second month in wounds healed by 
first intention, at the end of the third or fourth month in wounds healed by 
second intention, and they take origin directly from cell protoplasm and not 
from fibrous tissue (Minervini, in "Virchow's Archiv," vol. 175, No. 2). No 
genuine lymphatics exist in old scars but occasionally nerve filaments are 
present. Some dermal papillae are found after a time, but skin glands, skin 
muscle, and hair follicles remain absent. 

An old scar is smooth, whiter than the surrounding skin, somewhat creased 
or wrinkled and deficient in tactile sense. The scar of a healed tuberculous 
ulcer is irregular, livid, and often actually corrugated. The scar of a healed 
syphilitic ulcer is at first coppery-red and then glistening white and depressed. 
The scar of an old ulcer of the leg and of the skin about it is often darkened 
by pigmentation. 

A cicatrix may be discolored by retained foreign bodies, for instance, 
grains of gunpowder. 

During scar formation shreds of epidermis may be displaced and included 
in granulation tissue. Subsequently they are included in fibrous tissue and 
may then give rise to transplantation (implantation) dermoids or to epithelial 
tumors. A scar may be deformed, for instance, may be greatly depressed and 
adherent to underlying bone, and in certain situations such a scar will fix the 
jaws or any other joint. The vicious cicatrix is a great excess of a scar tissue 
and results from delayed healing by second intention. Such cicatrices are 
particularly common after burns and tuberculous ulcerations. In some cases 
the scar is irregular and lumpy, in other cases it is thickened at certain parts 
and discolored and resembles keloid. 

A cicatrix may block a natural orifice, as the mouth or nostril; may pro- 
duce great deformities, for instance, the head may be drawn upon the chest 
or shoulder by a contracting scar in the neck, fingers may be grown together 
after a burn, or a hideous depression may exist on the forehead after an injury, 
or the face may be fearfully contorted by contracting cicatrices. A scar may 
produce great disability by blocking the jaws, obstructing the rectum or ure- 
thra, or fixing a joint or certain muscles of an extremity. 

Most scars are insensitive, some are hypersensitive. The hypersensitive 
scars are usually thin and pale. The itching, burning or tingling appreciated 
in a sensitive scar are located, as a rule, at the junction of sound skin and 
newly-formed epidermis. Sometimes acute neuralgic pain exist in and about 
a scar due to pressure upon nerve filaments. 

A scar may inflame or ulcerate, warts may spring from its cutaneous sur- 
face, keloid may arise from the fibrous tissue, carcinoma may come from the 
epithelial elements (Marjolin's ulcer), sarcoma from the connective-tissue 
elements. 

Healing of Subcutaneous Wounds. — Blood fills the tissue gap and the 
blood-clots. Plasma exudes and corpuscles migrate into the clot and the 
tissue about it. The clot is eaten up by the leukocytes. The connective- 
tissue cells and the endothelial cells of the adjacent tissue proliferate and form 
fibroblasts, and fibroblasts multiply and replace the clot. The area of fibro- 
blasts is vascularized by the formation of new capillaries, and fibrous tissue 
forms and strongly contracts. 

Healing of Wounds in the Nonvascular Tissues. — In a trivial injury 



Repair of Nerve 117 

of the cornea a few leukocytes gather from the lymph-spaces and a few of the 
fixed cells proliferate. When the cornea is more severely wounded, an increased 
flow of lymph occurs. The nerves are irritated, vessels adjacent to the cornea 
distend, and many leukocytes invade the lymph spaces. The corneal cor- 
puscles multiply and alter in shape. The product of the process may be 
transparent if fibrin is absorbed and leukocytes pass away, because proliferating 
corneal corpuscles form transparent tissue. The surface epithelium is re- 
placed by proliferation of the deep layer of corneal epithelium. If the wound 
has penetrated the posterior portion, it is filled by proliferating epithelium 
from the membrane of Descemet. In a severe injury of the cornea endothelial 
cells and corneal corpuscles proliferate, vessels grow in from the corneal mar- 
gins toward the seat of inflammation, fibrous tissue forms, and permanent 
opacity results. 

Repair in cartilage, if it occurs at all, is very slow and is accomplished in 
the same way as repair in the cornea. Any severe injury is repaired by white 
fibrous tissue, furnished by the cells of the perichondrium, and the scar is 
permanent. 

Cell=division. — The multiplication of connective-tissue cells in repair 
may be by direct, but is usually by indirect, cell-division. Direct cell-division 
consists in division of the nucleus followed by division of the entire cell. 

Indirect cell-division, or karyokinesis, takes place after remarkable changes 
in the nucleus. The membrane of the nucleus disappears; the nuclear net- 
work becomes first close and then more open; and the cell becomes round, if 
not so before. The network of the nucleus, now consisting of one long fiber, 
takes the shape of a rosette; next it takes a star form — the aster stage; two 
sets of V's next form — the equatorial stage; an equatorial line appears and 
widens, and each set of V's retreats toward a pole. Thus two new nuclei are 
formed, each polar V passing in inverse order through the previous changes of 
shape, and the protoplasm of the original cell collecting about each nucleus 

(Fig. 63).. 

Repair of Nerve. — A nerve-fiber consists of a core known as the axis- 
cylinder, which is the essential element in function. About the axis-cylinder 
is an almost liquid material, known as the medullary sheath or white substance 
of Schwann, or myelin. The myelin is surrounded by a firm sheath known 
as the neurilemma (sheath of Schwann, primitive sheath, neurolemma). On 
its inner surface, or between it and the white substance of Schwann, are nuclei 
which are supposed by some to be peripheral nerve-cells (neuroblasts). The 
neurilemma is absent in the brain and cord. The continuity of the white 
substance of Schwann is interrupted at frequent intervals, and these breaks in 
the myelin are called nodes of Ranvier. Numbers of fibers of the kind just 
described, bound into bundles by connective tissue and surrounded by a 
fibrous sheath, constitute a nerve. It is known that a nerve may be regen- 
erated and completely regain function after division; that regeneration is 
strongly favored by suturing the ends together; and that if the ends of a di- 
vided nerve are more than one inch apart, regeneration will rarely take place 
unless they are sutured together. The method by which regeneration is affected 
has been much disputed and is still involved in uncertainty. If a nerve is 
divided, the peripheral segment at once loses its function and then undergoes 
degeneration (Wallerian degeneration). The degeneration begins within 



1 18 Repair 

twenty-four to forty-eight hours and affects the entire peripheral segment. 
The axis-cylinder perishes, the myelin runs into globules and is absorbed, 
leaving an almost empty sheath; the nuclei of the inner surface of the neuri- 
lemma proliferate for a time, but cease to do so before the myelin is completely 
absorbed. The sheath shrinks and looks empty, but here and there are col- 
lected masses of proliferated nuclei and protoplasm. Degeneration takes 
place in days, but regeneration requires months. Regeneration takes place 
by the multiplication of pre-existing nerve-fibers and not by the transforma- 
tion of connective tissue into nerve structure. The ends of a divided nerve, 
it is true, are united by connective tissue formed by the proliferation of fibro- 
blasts, but this connective tissue is only a bridge to carry nerve elements across 
the gap between the proximal and peripheral segments. The common view 
is that regeneration takes place as follows: The new axis-cylinder of the per- 
ipheral segment is a prolongation of the old axis-cylinder of the proximal seg- 
ment, projected in the following manner. A fiber, which is at first devoid of 
myelin, is prolonged from a proximal axis-cylinder; it divides into many cyl- 
inders, which pierce the granulation tissue between the ends and enter into the 
empty sheaths of Schwann of the distal segment or insinuate themselves be- 
tween these sheaths (Ranvier, Reclus, Senn). The above is the view enter- 
tained by those who teach that the new axis-cylinders come entirely and only 
from the prolongation of old axis-cylinders of the proximal segment, and that 
the distal segment is passive in the process until "neurotised" (Yanlair), and 
that regeneration is impossible in the distal segment unless it is in approxima- 
tion with the proximal segment or within easy reach of the prolongations of 
the axis-cylinders from above. Another view is that the axis-cylinders, myelin, 
and neurilemma are formed from cells which exist in the distal segment, and 
that juvenile axis-cylinders and medullary sheaths are formed in the peripheral 
portion and then effect a junction with like structures of the central segment. 
The last-mentioned view is advocated by Mayer and Eichhorst, Tizzoni, 
Cattani, and others, and Ballance and Stewart have recently published a most 
valuable monograph advocating it ("The Healing of Nerves"). The nuclei 
proliferate and form a mass of protoplasm within the old sheath, which pro- 
toplasm joins the proximal segment. Such a protoplasmic fiber has "con- 
duction and irritability" (Raymond's "Human Physiology"), but there is as 
yet neither myelin nor axis-cylinder. " The fiber is responsive to mechanical 
stimuli, but not to induction shocks, which latter property returns only after 
the axis-cylinder is developed. The medullary substance later appears and 
forms a tube; and still later the axis-cylinder is formed, having its origin in 
the central end of the nerve" (Raymond's "Human Physiology"). The 
views of Ballance and Stewart may be set forth as follows When a nerve- 
trunk is divided, the peripheral segment degenerates whether it has been 
sutured to the proximal segment or not, and the portion of the proximal seg- 
ment near the wound also degenerates. The injury produces at once an effu- 
sion of blood, migration of leukocytes takes place into and about the wound 
at the proximal segment, but leukocytic invasion of the entire distal segment 
is noted. After three days connective-tissue cells begin to replace the leu- 
kocytes, and after two weeks the excess of leukocytes is no longer observed, 
proliferated connective-tissue cells having taken their place (page 04, " Heal- 
ing of Nerves"). The proximal segment in the neighborhood of the wound 



Repair of the Spinal Cord and Brain 119 

and the entire distal segment are invaded by proliferating connective-tissue 
cells. The connective-tissue cells completely absorb the fatty myelin and axis- 
cylinders. The cells of the neurilemma actively multiply, and connective- 
tis-ue cells lving among chains of neurilemma cells become spindle-shaped 
and "the degenerated nerve-trunk therefore becomes hard, fibrous, and cir- 
rhosed" (Ballance and Stewart on the " Healing of Nerves," page 94). 

In the proximal end of a divided nerve an "end-bulb" is formed. This 
was long supposed to be due to the prolongation of nerve-fibers from the 
central fibers and a turning backward because they cannot cross the gap. As 
a matter of fact, the ends of the divided fibers curl up; on and in this scaffold- 
like arrangement new fibers are placed, they having been produced by the 
neurilemma cells which have taken on " neuroblastic function" (Ballance and 
Stewart . When a nerve has been sutured, the earliest signs of regeneration 
•"occur at the end of three weeks" (Ballance and Stewart). Short lengths of 
new fibers are laid down within old neurilemma sheaths. The new axis- 
cylinder " is seen to consist in the deposition along one side of a spindle-shaped 
neurilemma cell, of a thin thread which grows in length until it projects beyond 
the limits of the parent cell and stretches on toward its next neighbor in the 
same longitudinal row" (Ballance and Stewart). The new medullary sheath 
is "laid down bv a process of secretion" (Ballance and Stewart) along the 
sides of the neurilemma cells. 

Ballance and Stewart go on to point out that if the central theory of regen- 
eration is true, not a trace of regeneration could occur in the distal segment 
when the two segments have not been united by sutures, and yet such regen- 
eration does occur, although slowly, the new axis-cylinders and medullar}- 
sheaths not attaining full size. "Evidently some stimulus afforded by the 
conduction of impulses is necessary in order to permit of their full develop- 
ment" (Ballance and Stewart). In the notable study quoted at such length 
are some experiments on the "conduct and fate of transplanted nerve." When 
the gap is wide between the two ends, a portion of fresh nerve-trunk may be 
inserted to bridge it. The transplanted piece degenerates; it is invaded by 
leukocvtes, and proliferating connective-tissue cells, medullary sheaths, and 
axis-cvlinders are destroyed, but regeneration may subsequently occur; "but 
when it does occur, it is not from the activity of the cells of the graft itself" 
(Ballance and Stewart). Blood-vessels enter the degenerated graft at each 
end and they are accompanied by chains of neurilemma cells, which form 
axis-cylinders and medullary sheaths. The graft is merely a scaffold (Ballance 
and Stewart). 

The studies of Ballance and Stewart persuade us that regeneration does 
occur in the distal part independently of the proximal part, although full de- 
velopment does not take place unless there is a junction with the central part. 
As to the exact method of regeneration we still feel somewhat uncertain. 
When we remember that the nerve-fibers of the spinal cord are devoid of 
neurilemma and that the cord can, to some extent at least, regenerate, we 
must conclude that regeneration can take place in the cord without the aid 
of neurilemma cells, and must infer that the same may be true in a nerve. 

Repair of the Spinal Cord and Brain . — Can the spinal cord regenerate ? 
Many observers have doubted it. But there is no doubt of the fact that some- 
times, after the subsidence of an acute myelitis or after the relief of a pressure 



120 



Repair 



which produced complete and prolonged paralysis, there is a return of func- 
tional power. It is usually assumed that restoration is possible in fibers which 
have not been hopelessly damaged, but is not possible in those which have been 
destroyed; but, as Gowers says, there are cases in which "we can scarcely 
believe that the axis-cylinders retain their continuity, although conducting 
capacity is ultimately restored." Clinical evidence indicates strongly that 
the pyramidal fibers may regenerate. Mills says ("The Nervous System and 
Its Diseases"): "Nerve-tracts in the spinal cord and brain have power to 
regenerate, but this is not so great as in the peripheral nerves, and yet even old 
cases of compression of the spinal cord may make great improvement after a 
long time, largely through the regeneration of the columns of the cord." 
Mills affirms that although nerve-cells sometimes appear to regenerate, the 
destruction in these cases was not complete. 

When axis-cylinders have been destroyed in the cord and yet some power 
returns, we ask ourselves if this occurs because new fibers have grown down 
from above. Gowers says that such a growth has been proved to occur in the 

lower animals, but has 
not as yet been demon- 
strated in man; although 
specimens have been de- 
scribed which strongly 
suggest such an occur- 
rence in the human sub- 
ject. That the cord can 
regenerate to some ex- 
tent seems highly proba- 
ble from the report of a 
recent case. Dr. Francis 
T. Stewart, of Philadel- 
phia, sutured a com- 
pletely divided spinal cord and an extraordinary restoration of function took 
place (Francis T. Stewart and Richard H. Harte, in " Phila. Med. Journal," 
June 7, 1902). This case is commented on at some length in the section on 
Injuries of the Spinal Cord. Another somewhat similar case was reported 
by George Ryerson Fowler in the "Annals of Surgery," Oct., 1905. 

Many claim that a brain injury cannot be followed by repair with restora- 
tion of function; some think that complete regeneration can take place; others, 
that partial regeneration may occur. Yitzon and Tedeschi even believe that 
nerve-cells in the brain can regenerate. It seems probable that extensive 
injuries are not repaired, but slighter ones may be, new ganglion-cells and 
neuroglia being formed. Tedeschi describes the process of repair after a 
wound of the brain as follows: Degeneration occurs and a limited focus of 
necrosis forms and then the adjacent tissue shows evidences of repair. Capil- 
laries form from the endothelial cells, glia tissue from the neuroglia, ganglion- 
cells present karvokinetic changes, and some nerve-fibers appear in the scar 
(Senn's "Principles of Surgery"). 

Repair of Muscles. — It has long been taught that the repair of muscle 
by muscle is impossible, and, as a matter of fact, it does not take place if the 
ends of a divided muscle are separated to the extent of an inch or more. When 




Fig- &3- 



-Forms assumed by a nucleus dividing (Green, from 
Flemmino;). 



Repair of Muscles 



121 



a muscle is divided transversely by a considerable cut, the ends retract and a 
wide space is left between them. Blood flows into the space between the ends 
and also between individual fibers of the injured muscle, and the blood-clots. 
Exudation of plasma occurs and migration of curpuscles takes place. Fibro- 
blasts are produced by proliferation of connective-tissue cells and a mass of 
fibroblasts soon replaces the blood-clot. Granulation tissue is formed by 
vascularization of the mass of fibroblasts, and granulation tissue is converted 
into scar tissue, but not at all into muscle. After slight injuries a trivial 
amount of muscular regeneration does occur by the multiplication of living 
muscle-cells, but not by metamorphosis of fibroblasts. Fibroblasts are in- 




Fig. 64. — Fracture otic week : blood- Fig. 65. — Callus of fracture Fig. 66. — Femur of a child 

clot containing fragment of bone (War- (dog) four weeks : commenc- fifth week after fracture 

ren). ing ossification of external (Warren). 

callus (Warren). 

capable of a transformation into muscular tissue. When the ends of a divided 
muscle are separated only to a very slight degree or when they have been 
brought together and sutured, some muscular regeneration occurs. After an 
injury a number of the muscular fibers wither, perish, and are absorbed. The 
process of regeneration arises from the remaining fibers. The nuclei of the 
muscle-fiber proliferate and so do the nuclei of the perimysium. The muscle- 
cells are called myoblasts and the nuclei of the perimysium are called sarco- 
blasts. About the juvenile muscle-cells a deposit of protoplasm takes place 
(Weber). The embryonal cells gradually become spindle-shaped and mus- 
cular fiber is formed by cellular fusion or by elongation of individual cells. 



122 Repair 

i 

The above remarks refer to striated muscle. Unstriated muscle fibers 
are repaired solely by "indirect multiplication of their nuclei" (Senn). 

If a muscle has been divided, it should be sutured. This process insures 
more rapid repair and secures a better functional result, and is followed by 
a much greater amount of muscular regeneration. 

Repair of Tendon. — When a tendon is divided, the ends retract, and the 
sheath, as a rule, becomes filled with blood-clot. The blood-clot is rapidly 
removed, fibroblasts replacing it. This new tissue arises from the sheath, 
the cut ends of the tendon not participating in its formation. Granula- 
tion tissue is formed; this is converted into fibrous tissue, and after a time the 
fibrous tissue becomes true tendon. If no blood-clot forms in the sheath, the 
walls of this structure collapse and adhere, and the separated tendon-ends 
are held together by a flat fibrous band formed from the collapsed sheath 
(Warren's " Surgical Pathology"). 

Repair of Bone. — When a bone is broken, a blood-clot quickly forms in 
the medullarv cavity, between the broken ends and under and outside the peri- 
osteum. Leukocytes invade and destroy the clot. The cells outside the peri- 
osteum, the cells of the periosteum and of the medullary tissue, particularly 
the endothelial cells, proliferate and produce cells which are practically fibro- 
blasts. The osteoblasts in the medullary tissue and in the deeper layers of 
the periosteum multiply and are distributed through the mass of fibroblasts. 
The osteoblasts may form bone directly or may form cartilage first. Some 
teach that fibroblasts can be converted into bone; others positively deny such 
a conversion. The point is not settled, but it is well to remember that in 
myositis ossificans a muscle is converted into bone, and hence that it is prob- 
able that fibroblasts, formed from periosteum and medullary tissue, should be 
much more prone to undergo such a development. During regeneration the 
bone ends soften and are partially absorbed by osteoclasts. These cells are large 
osteoblasts which have lost the power of bone production and furnish a secre- 
tion which dissolves osseous matter. The excess of callus is finally absorbed 
by osteoclasts. (For a more extended description see Repair of Fractures.) 

Repair of Blood=vessels. — If an artery is cut across and ligated, a clot 
forms within its lumen and about its divided end, and the circulation in the 
vessel at this point is permanently arrested. The proximal clot, it used to be 
thought, always reaches the first collateral branch. This statement was true 
before the days of asepsis; it is not always true now. Often a clot stops far 
short of the branch above. Exudation of plasma and migration of corpuscles 
take place from the vasa vasorum. The clot becomes filled with leukocytes, 
which gradually destroy it, and it plays no active part in repair. Fibroblasts 
form by the multiplication of the cells of the vessel wall and the clot is soon 
replaced by fibroblasts. The fibroblasts are converted into granulation tissue, 
granulation tissue becomes fibrous tissue, the fibrous tissue contracts, and the 
artery is transformed into a fibrous cord (Fig. 183). Warren insists that the 
muscle-cells of the middle coat play an active part in repair. Usually, when a 
ligature is applied to an artery in continuity, a deliberate attempt is made to 
rupture the internal and middle coats, in order to permit of contraction and 
retraction above and below the seat of ligature, and a turning inward of the 
inner coat. Such a sequence of events happens when an artery is completely 
divided across and not tied, and favors the rapid formation of a clot. 



Benign Traumatic Fever 123 

Ballance and Edmunds ("Ligation in Continuity") maintain that repair 
is obtained most rapidly when the artery is tied with two ligatures, the vessel 
at this point being deprived of blood, but the internal and middle coats being 
kept intact. Cell-proliferation forms a spindle-shaped mass of new cells and 
the lumen is obliterated at the seat of ligation by fibroblasts obtained from 
the fixed cells of the wall of the artery. Senn advocates the employment of 
two ligatures, not placed side by side as in the method of Ballance and Ed- 
munds, but so applied as to include "a bloodless space about half an inch in 
length" (Senn's " Principles of Surgery"). 

When a lateral ligature is applied to a vein or when a small wound in a 
vein or artery is sutured, the circulation in the vessel is not completely cut off, 
a thrombus of small size is formed on the vessel- walls, the fixed cells of the 
vessel-wall proliferate, and a scar of fibrous tissue effects repair. A com- 
pletely divided vein heals as does a completely divided artery (Fig. 184). 
The clot after the aseptic application of a ligature to a vein may be of slight 
extent, but in some cases the proximal clot reaches the first collateral branch 
and in others goes far above it. 

Repair of Skin. — The fibrous structure is repaired by fibrous tissue. 
Hair follicles, sweat-glands, and sebaceous glands are not reformed. The 
epithelial layer is regenerated by the proliferation of adjacent epithelial cells. 

Repair of Lymphatic Tissue. — Lymphatic tissue can regenerate either 
from the fatty tissue, the divided ends of the lymph ducts or both structures. 

Repair of the Kidney and Testicle. — These organs when damaged can 
undergo some regeneration. 

Repair 0} the Liver and Spleen. — Each of these organs, after injury, is 
capable of considerable regeneration. 



V. SURGICAL FEVERS. 

The surgeon encounters fever as a result of an inflammation or an aseptic 
wound, in consequence of infection, as a result of poisoning by certain drugs, 
and in several maladies of the nervous system. It is important to remem- 
ber that, while elevated temperature is generally taken as a gauge of the in- 
tensity of fever, it is not a certain index. There may be fever with subnormal 
temperature (as in the collapse of typhoid or pneumonia), and there may be 
elevated temperature without true fever (as in certain diseases of the nervous 
system). It is true, however, that elevation of temperature is almost always 
noted, and is usually accepted as the measure of the severity of the fever. 

The essential phenomena of fever, according to Maclagan, are — (1) wasting 
of nitrogenous tissue; (2) increased consumption of water; (3) increased 
elimination of urea; (4) increased rapidity of circulation; and (5) preternat- 
ural heat. 

Traumatic fevers follow a traumatism and attend the healing or in- 
fection of a wound. The forms are — (1) benign traumatic fever; (2) malig- 
nant traumatic fever. 

Benign traumatic fever is divided into two forms — the aseptic and the 
septic. There is but one form of aseptic fever, the post-operation rise. The 
septic benign fevers are surgical fever and suppurative fever. The malignant 



124 Surgical Fevers 

traumatic fevers are sapremia, septic infection, and pyemia. In this section 
we discuss only the benign fevers. 

Aseptic traumatic fever, or the post-operation rise, often, but not always 
appears after a thoroughly aseptic operation and after a simple fracture or a 
contusion. It is not preceded by a chill, by chilliness, or by a feeling of illness. 
It may appear during the evening of the day of operation or not until the next 
day, and reaches its highest point by the evening of the second day ( ioo° to 103 
F.). This elevation is spoken of as the ''post-operation rise" because it is 
usually encountered after an operation. Besides the elevated temperature 
there are no obvious symptoms; the patient feels well, sleeps well, and often 
wants to sit up; there are no rigors and there is no delirium. The wound is 
free from pain and appears entirely normal. But examination may show mod- 
erate leukocytosis. This fever is due to absorption of pyrogenous material 
from the wound area, the material being obtained from clot or inflammatory 
exudate, or from both. Many observers believe that the pyrogenous element 
is fibrin ferment, which is absorbed from disintegrating blood-clot and coagu- 
lating exudate. Warren thinks the fever is due to fibrin ferment, and "also 
to other substances slightly altered from their original composition during life." 
Some have asserted that the fever is due to nervous shock. 

Schnitzler and Ewald have recently studied aseptic fever.* These ob- 
servers maintain that aseptic fever can exist when no fibrin ferment is free in 
the blood, that fibrin ferment can be free in the blood when there is no fever, 
and, in consequence, that fibrin ferment is not the cause of the elevation 
of temperature. They rule out of consideration nervous shock as a cause, and 
assert that a combination of several factors is responsible, nucleins and 
albumoses which are set free by traumatism being looked upon as the most 
active causative agents. The presence of nuclein in the blood in aseptic 
fever is indicated by leukocytosis and by the increase of the alloxur bodies 
(including uric acid) in the urine. The capacity of nucleins and albumoses 
to cause fever is greater in the tuberculous than in the non-tuberculous, and 
we know clinically that a tuberculous patient is apt to exhibit a more violent 
post-operation rise than is a non-tuberculous subject. The diagnosis of asep- 
tic traumatic fever is only to be made after a careful examination has assured 
the surgeon that there is no obscure or hidden area of infection. 

In some cases aseptic fever may appear after an operation, and later be 
replaced by a septic fever. If the temperature remains high after a few days, 
if other symptoms appear, or if after the temperature has become normal it 
again rises, the wound should be examined at once, as trouble almost certainly 
exists. 

True traumatic or genuine surgical fever is seen as a result of in- 
fected wounds in which there is decided inflammation, but no pus. The 
real cause is the presence of fermentative bacteria in the wound and 
the absorption of a moderate amount of their toxic products. The 
most active and commonly present organisms are those of putrefaction. 
Surgical fever ceases as soon as free discharge occurs, and the ap- 
pearance of such a fever is an indication for instant drainage. The 
condition is ushered in two or three days after the operation by chilly sen- 

*See Archiv fur klinische Medicin, Bd. liii, H. 3, 1896; also statement of their views 
in Medical Record, Dec. 19, 1896. 



Fever of Morphinism 125 

sations and general discomfort. The temperature rises pretty sharply, 
ascends with evening exacerbations and morning remissions, and reaches its 
height about the third or fourth day, when suppuration sets in; the tempera- 
ture begins to drop when pus forms, if the pus has free exit, and reaches 
normal at the end of a week (see Suppurative Fever). The temperature may 
reach 104 F. or more, but rarely rises above 103 F. The patient has the 
general phenomena of fever, that is to say, thirst, anorexia, nausea, dry and 
coated tongue, constipation, pain in the back and legs, and headache. The 
urine is scanty and high-colored. Blood examination usually shows decided 
leukocvtosis. The wound is painful, tender, swollen, discolored, and often 
foul, and stitch-abscesses may form. Some or all of the stitches must be cut, 
and the area should be asepticized, and packed with iodoform gauze or 
drained by a tube. The fact that this fever is apt to cease when discharge 
of pus begins led the older surgeons to hope for pus and to endeavor to cause 
it to form. A severe grade of surgical fever, such as arises when there is 
putrefaction in a large and ill-drained wound, is due to the absorption of a 
large quantity of the toxic products of putrefactive bacteria and is known as 
sapremia (page 195). 

Suppurative Fever. — This fever, which is due to the absorption of the 
toxins of pyogenic organisms, occurs after suppuration has begun, is found 
when the pus has not free exit, and is an intoxication rather than an infection. 
It can follow or be associated with surgical fever, or may arise in cases in which 
surgical fever has not existed. Suppuration in a wound is indicated by a rapid 
rise of temperature — possibly by a chill. The temperature rises to a con- 
siderable height, shows morning remissions and evening exacerbations, and 
as it begins to fall toward morning sweating occurs. The patient is much 
exhausted and presents the phenomena of fever previously described. The 
skin about the wound becomes swollen, dusky in color, and edematous, 
pain becomes pulsatile, and much tenderness develops. Blood examination 
shows very marked leukocytosis. The wound must at once be drained and 
asepticized. In a chronic suppuration, such as occurs when there is 
pvogenic infection of a tuberculous area, there exists a fever with marked 
morning remissions and vesperal exacerbations, attended with drenching 
night-sweats, emaciation, diarrhea, and exhaustion. This is known as hectic 
fever; it is really a chronic suppurative fever. The treatment of hectic fever 
consists in the drainage and disinfection, if possible, the excision of the infected 
area, the employment of a nutritious diet, stimulants, tonics, remedies for the 
exhausting sweats, and free access of fresh air. 

Some Other Forms of Fever Seen by the Surgeon.— Fever of 
Tension. — When there is great tension upon the stitches the spots where the 
stitches perforate ulcerate and some fevers arise. To relieve the fever of 
tension cut one or several stitches. This fever is in some cases surgical, and 
in some suppurative, according as to whether the infective organisms cause 
fermentation or suppuration. 

Fever of Iodoform Absorption (see page 30). 

Fever of Ptyalism, or Mercurial Fever (see page 291). 

Fever of Morphinism. — Sometimes a morphia habitue suffers from se- 
vere chills and intermittent fever of the quotidian or tertian type. The con- 
dition is usuallv thought to be malarial, a view which is strengthened by the 



126 Surgical Fevers 

common association with neuralgia; but quinin proves futile as a remedy 
and blood-examination gives a negative result. If we have reason to suspect 
that the patient is using morphia, examine the urine for the drug and wash 
out the stomach and examine the washing. The latter test is of value even 
when morphin is used hyperdermatically, because that drug is excreted into the 
stomach. 

Fever of Cocain-poisoning (see Local Anesthesia). 

Hepatic Fever (see section on Liver and Gall-bladder). 

Hysterical Fever. — This remarkable condition is occasionally, though 
seldom, encountered. Most of the reported cases of great hyperpyrexia are 
instances of simulation and fraud. It may happen that elevated temperature 
is the sole evidence of illness, there being no wasting or other febrile symp- 
toms. Such elevated temperature may be attained daily for months. As a 
rule, hysterical stigmata can be detected. Osier points out that cases of 
hysterical fever "with spurious local manifestations" are very deceptive. 
The case may resemble meningitis, peritonitis, or some other acute inflam- 
matory condition; but the course of the supposed malady is found to be 
atypical and the symptoms are observed to be variable and often anomalous. 
There is no leukocytosis; frequently there is an apparent increase in red cells 
because of vasomotor disturbance, a fall in hemoglobin, and an increased 
proportion of lymphocytes and eosinophiles (''Clinical Hematology," by J. C. 
DaCosta, Jr.). 

An emotional fever sometimes occurs after accidents or operations. 
The patient may have a chill, and then develop violent headache, photo- 
phobia, and hysterical excitement, with elevated temperature. 

Malaria. — It is wise to examine the blood in supposed septic fevers, for 
only by this means can malaria be excluded. It is more common to mistake 
sepsis for malaria than malaria for sepsis. In malaria the spleen is enlarged, 
the febrile attacks exhibit periodicity, neuralgias are common associates, and 
quinin cures the condition. 

Surgical Scarlet Fever. — It is maintained by some writers (notably Sir 
Victor Horsley and Sir James Paget) that a child is rendered especially sus- 
ceptible to scarlet fever by the shock of a surgical operation. Scarlet fever 
which develops after a wound, a burn, or an operation is spoken of as surgical 
scarlet fever. Warren quotes Thomas Smith as having had ten cases of 
scarlet fever in forty-three operations of lithotomy in children. The puer- 
peral state is supposed also to predispose to scarlet fever. It is not certain 
whether the poison enters by the wound, or whether shock and exhaustion 
predispose to ordinary scarlatina, or whether ordinary scarlatina was incu- 
bating before the accident or operation. Some surgeons hold that an attack 
of scarlet fever after an operation is a mere coincidence. Others maintain, 
and with great show of reason, that a red scarlatiniform eruption appearing 
after an operation, rarely indicates genuine scarlet fever, but usually points 
to infection, as such eruptions are known occasionally to arise in septicemia. 
It rarely indicates scarlet fever, and yet it sometimes does. There is such a 
condition as surgical scarlet fever, as is proved by the facts that victims of 
the disease have been known to communicate it, and that it is often followed 
by "nephritis and usually by desquamation" (Holt's " Diseases of Infancy 
and Childhood"). 



Suppuration 127 

Hoffa has discussed this subject elaborately. He concludes that four types 
of eruption can follow operation: (1) a vasomotor disturbance due to irrita- 
tion of sensory nerves, and manifested by a transient urticaria <>r erythema: 
(2) a toxic erythema due to absorption of aseptic pyrogenous material from 
the injured area — the absorption of carbolic acid, iodoform, of corrosive 
sublimate, or the effect of ether; (3) an infectious rash which is sometime- 
found in septicemia or pyemia, and is due to minute emboli composed of bac- 
teria, which emboli lodge in the capillaries; (4) true scarlet fever, with the 
usual symptoms and complications, the micro-organisms having entered by way 
of the wound and the eruption often beginning at the wound edges (quoted 
in Warren's "Surgical Pathology"). Surgical scarlatina is aberrant. It de- 
velops rapidly, the period of incubation is extremely brief, and the throat may 
or may not be involved. Holt tells us that the rash is usually atypical and that 
"the general symptoms, particularly those relating to the nervous system.*' 
are "especially severe" ("Diseases of Infancy and Childhood"). The in- 
fection is believed to be due to a specific germ, but it has not been certainly 
identified. Streptococci have been found in the throat, skin, and the pus from 
secondary otitis media. 

If surgical scarlet fever develops the wound should be drained and asepti- 
cized, and if the situation admits of it, dressed with hot antiseptic fomentations. 
The general treatment is the same as for ordinary scarlatina. 

Urinary Fever and Urethral Fever (see section on Disease of Genito- 
urinary Organs). 

Syphilitic Fever (see page 279). 

Thyroid Fever (see section on Thyroid Gland). 



VI. SUPPURATION AND ABSCESS. 

Suppuration is a process in which damaged living tissues and inflamma- 
tory exudates are liquefied by the action of pyogenic organisms, and it is a com- 
mon result of microbic inflammation. The organisms which are responsible 
are referred to on page 42. Staphylococci tend to produce local suppuration; 
streptococci tend to cause spreading suppuration. It is generally taught that 
pyogenic bacteria liquefy damaged tissue and exudate by peptonizing them, 
the active agent in effecting the chemical change being poison furnished by 
the bacteria. There is some evidence that white corpuscles by disintegration 
set free enzymes which dissolve or aid in dissolving albumin. Streptococci 
and staphvlococci vary greatlv in virulence and the intensity and diffusion of 
a pvogenic infection depends upon the virulence and number of the bacteria 
and the level of vital resistance. Streptococci and staphylococci may both be 
present in one focus, and there may be secondary infection with bacteria of put- 
refaction or other bacteria. The pyogenic infection may be primary or it may 
be secondarily implanted in a diseased area containing other micro-organisms. 
The pyogenic organisms are very irritant, and when deposited cause in- 
flammation; inflammation leads to exudation, but the exudate cannot co- 
agulate or coagulates but imperfectly, because it is peptonized by the fer- 
ment of the micro-organisms and also perhaps because albumin is dissolved 
by leukolysin from the white corpuscles. If an area of embryonic tissue is 



128 Suppuration and Abscess 

invaded by the pyogenic micro-organisms, it is promptly peptonized. The 
peptonizing action is upon the fibrinous elements of an exudate and upon the 
intercellular substance of embryonic or granulation tissue. Cells are separated 
from intercellular substance, and in consequence degenerate and die. Pep- 
tonized exudate or peptonized embryonic tissue is called pus. In suppurations 
induced by staphylococci a barrier of leukocytes is first formed around the region 
of irritation ; this barrier is reinforced by fibroblasts, the pus is imprisoned, and 
rapid spreading and wide diffusion are prevented. In inflammations induced 
by streptococci the peptonizing action of the organisms is so great that no 
barrier of white blood-cells or of proliferating connective-tissue cells forms in 
time to imprison the micro-organisms; hence the suppuration spreads rapidly 
and widely. Suppuration can be induced by the injection of pyogenic bacteria, 
by their entry through a wound, and by rubbing them into the skin. In 
some rare instances, especially when the diet has been putrid, they may enter 
through the blood and lodge at a point of least resistance. When a medullary 
canal suppurates after a chill to the surface or after a blow that does not cause 
a wound, we know that the bacteria must have arrived by means of the 
blood. Bacteria which reach a point of least resistance through the blood 
come from some atrium of infection which may be discoverable or which may 
not be found. The entry of pyogenic bacteria does not necessarily cause 
suppuration, as the health}- human body can destroy a considerable number, 
even if given in one "dose"; but a large number in a healthy, or even a small 
number in an unhealthy body, almost certainly leads to pus-formation. 
The pus of all acute abscesses contains bacteria of suppuration, but the pus 
of tuberculous abscesses does not, unless there be a mixed infection; in other 
words, pure tuberculous pus is not pus at all. 

Can suppuration be induced without the actual presence of bacteria ? It is 
true that the injection of irritants can cause the formation of a thin fluid which 
contains no bacteria; but this non-bacterial fluid is not pus. A purulent fluid 
is formed by injecting cultures of pus cocci which have been rendered sterile by 
heat, the bacteria having been killed, and a ferment contained in the bacterial 
cells being the active agent. Purulent material also results from the injection 
simply of the sterile products of the growth of pyogenic cocci. This purulent 
or sterile fluid is known as spurious or aseptic pus. An area of such aseptic 
suppuration does not tend to spread and the process concerns us but little as 
surgeons, except in cases of pyemia in which thrombi containing toxins alone 
may occasionally induce limited secondary abscesses. 

Impaired health or an area of lowered vitality predisposes to suppura- 
tion. Diabetes and albuminuria are common and influential predisposing 
causes, because in these diseases tissue resistance is always at a low ebb. 
The lymphatic glands, medulla of bones, serous membranes, and connective 
tissue are especially prone to suppurate. 

Pus may form within twenty-four hours after bacteria have been deposited, 
or it may not be formed for days. The older surgeons claimed that pus could 
do good by protecting granulations and separating disorganized tissue. It 
is now held that it is absolutely harmful by melting down sound tissue and 
poisoning the entire organism. Modern surgery has to a great degree abolished 
pus. 

If pus stands for a time, it separates into two portions — (i) a watery por- 



Forms of Pus 



129 



tion, the liquor puris or pus-serum, containing peptone, fat, microbic products, 
osmazone, and salts, and not tending to coagulate; (2) a solid portion, or 
sediment composed of dead and living micro-organisms of suppuration, connec- 
tive-tissue cells, often epithelial cells, perhaps red blood-cells, lymphocytes, 
pus-corpuscles (Fig. 67), debris of tissue, and shreds of dead tissue. The 
pus-corpuscles are either polynuclear white blood-cells or altered connective- 
tissue cells containing many nuclei. Some of them are dead, some have ame- 
boid movements, some are fatty, others are granular and contain more than one 
nucleus, and all are degenerating. A pus-cell is waste matter, and it cannot 
aid in repair. Very exceptionally pus disappears by absorption, by caseation, 
or by calcification. 

Pus in General.— The color of pus is variable and depends upon the na- 
ture of the bacteria; the presence or absence of blood, fibrin, body secretions 




Fig. 67. — Fragmentation ot nucleus in leukocytes undergoing transformation into pus-corpuscles 

(Senn). 



or body excretions (bile, urine, mucus, feces, etc.); and the existence or non- 
existence of putrefaction. 

Its consistence varies. In some cases it is scarcely thicker than water, in 
others it is like cream and in still others it is cheesy. Thick pus is usually 
of a greenish-yellow color and thin pus has usually a reddish or yellowish 
tinge (Leonard Freeman). When freshly evacuated many varieties are almost 
or quite odorless, and are alkaline or slightly acid in reaction. 

Some varieties possess a very offensive odor. Pus contaminated by the 
bacteria of putrefaction is certain to have a foul odor. Pus which forms in the 
tonsil, in the brain, about the vermiform appendix, or around the rectum usu- 
ally possesses an offensive odor. 

Forms of Pus. — Laudable, or healthy pus, a name long in vogue, is a con- 
tradiction, no pus being healthy. In former days free suppuration after an 
operation was regarded as a favorable indication, and when it occurred the 
9 



130 Suppuration and Abscess 

surgeon congratulated himself that surgical fever was at an end. At the 
present day suppuration after an operation is an evidence of previous infection, 
of lack of care, failure in our precautions, or of infection by the blood. The 
so-called laudable pus is seen coming from a healing ulcer, and is an opaque, 
yellowish-white, or a greenish fluid of the consistence of cream, without 
odor or with a very slight odor if it is not putrid, and having a specific gravity 
of about 1030. 

Malignant, watery, or ichorous pus is a thin, watery, putrid fluid. It is 
pus filled with the organisms of putrefaction. 

Stinking pus may be ichorous. Its odor may be due to the bacterium coli 
commune. If this bacterium is the cause the pus is very foul, but not thin. 
Pus of this nature is met with in ischiorectal abscess and appendiceal abscess. 
Its odor may be due to ordinary bacteria of putrefaction, in which case the 
pus is thin. 

Sanious pus is a form of ichorous pus containing blood coloring-matter 
or blood. It is thin, of a reddish color, and very acrid, corroding the parts 
that it comes in contact with. It is found notably in caries and carcinoma. 

Concrete or fibrinous pus, which contains flakes of fibrin or coagulated 
fibro-purulent masses, is met with in serous cavities (joints, pleura, etc.). 
These masses also form in infective endocarditis. 

Red pus signifies the presence of the bacillus prodigiosus. 

Blue Pus. — The color of blue pus is due to the bacillus pyocyaneus. 

Orange Pus. — The color of orange pus is due either to the action of sarcina 
aurantiaca, or to the formation of crystals of hematoidin from the coloring- 
matter of red blood-cells which have been mingled with the pus. Pus of this 
color appears only in violent inflammations. 

Serous pus is a thin serous fluid containing a few flakes. 

So-called tuberculous, scrofulous, or curdy pus is not pus at all, unless the 
tuberculous area has undergone pyogenic infection. 

So-called gummy pus arises from the breaking down of a gumma which 
has outgrown its own blood-supply. It is not pus. 

Muco-pus is found in purulent catarrh — that is, in suppurative inflammation 
of an epithelial structure. It contains pus elements and epithelial cells. 

Caseous pus comes from the fatty degeneration of pus-corpuscles or in- 
flammatory exudations. It occurs especially in tuberculous processes. A 
caseous mass may calcify. 

Signs and Symptoms of Suppuration. — Suppuration is announced by 
the intensification of all local inflammatory signs. The heat becomes more 
marked, the discoloration dusky, the swelling augments, the pain becomes throb- 
bing or pulsatile, and the sense of tension is greatly increased. The skin at the 
focus of the inflammation after a time becomes adherent to the parts beneath, 
and fluctuation soon appears. This adhesion of the skin is a preparation for a 
natural opening, and is known as pointing. An important sign of pus beneath 
is edema of the skin. This is always observed in a superficial abscess, and is 
sometimes noticeable in empyema or pyothorax, in appendiceal abscess, and 
in perirenal suppuration. The above symptoms can be reinforced and their 
significance proved by the introduction of an aseptic tubular exploring needle 
and the discovery of pus. Irregular chills, high fever, drenching sweats, weak- 
ness, and a feeling of serious sickness are very significant of suppuration in an 
important structure or of a large area. It must always be remembered that in 



Wooden or Ligneus Phlegmon 131 

some virulent pyogenic infections the human organism is overwhelmed with 
toxins and although the patient is desperately ill the temperature is normal 
or even subnormal. In abscess of the brain the temperature may be normal 
or subnormal. 

Diffused Cellulitis or Phlegmonous Suppuration; Purulent Infil- 
tration. — This process may involve a small area or an entire limb, and is due 
to infection by the streptococcus pyogenes (or streptococcus of erysipelas) 
usually associated with mixed infection with other bacteria particularly the 
bacteria of putrefaction. The streptococci are intensely virulent. Barriers 
of white corpuscles will not restrain them, and tissues break down before cellu- 
lar multiplication is able to encompass the bacteria. The bacteria disseminate 
through the lymph-spaces and lymph-vessels. The disease in severe cases 
produces enormous swelling, areas which feel boggy, a dusky red discoloration, 
and great burning pain. Gangrene of superficial areas is not unusual, due to 
thrombosis of vessels or coagulation necrosis from toxins. The discharges 
of the wound, if a wound exists, are apt to dry up, and the wound becomes foul, 
dry, and brown. The adjacent lymphatic glands are much enlarged. The 
disease is ushered in by a chill, which is followed by high oscillating tempera- 
ture, due to suppurative fever, sapremia, or even septic infection or pyemia. 
Sweats are noted during falling temperature. Diffuse suppuration tends to 
arise in infected compound fractures, in extravasation of urine, and after the 
infliction of a wound upon a person broken down in health. It is not unusual 
after typhoid or scarlet fever, and is typical of phlegmonous erysipelas. The 
pus is sanious and offensive, and burrows widely in the subcutaneous tissue and 
intermuscular planes. This diffused suppuration may widely separate muscles 
and even lay bare the bones. It is a very grave condition, and may cause death 
by exhaustion, septic intoxication, septic infection, pyemia, or hemorrhage 
from a large vessel which has been corroded. Cellulitis of a mild degree is due 
to attenuated streptococci or to staphylococci. An area of cellulitis may sur- 
round an infected wound or a stitch-abscess. Its spread is manifested by red 
lines of lymphangitis running up to the adjacent lymphatic glands. Light 
cases may not suppurate, the lymphatics carrying off the poison. Any case of 
cellulitis is, however, a menace, and any severe case is highly dangerous (see 
Erysipelas). 

Wooden or Ligneus Phlegmon. — This condition was fully described by 
Reclus in 1894. It is chronic inflammation of the cellular tissue and fascia of 
the neck. It is a very chronic condition beginning with hard swelling of one 
side or of the front of the neck and for weeks is unaccompanied by any other sign. 
The swelling may be at first localized, but it spreads slowly and widely and 
finally comes to involve an extensive area, even perhaps the front of the neck and 
both sides from the jaw to the collar-bone. It may involve the cervical muscles 
and thus create rigidity and it may compress the larynx and trachea and thus 
interfere with breathing. After weeks or perhaps a month or two the skin 
becomes edematous and red or rather of a violet hue. There is rarely pain and 
the significant facts are the gradually advancing hard swelling long unac- 
companied by pain, discoloration, or cutaneous edema. The condition is due 
to the deposition and multiplication of pyogenic bacteria which reach the tissues 
from the lymph-glands and reach the glands from the mouth. Pus does not 
form at all or only minute encapsuled foci form because the bacteria are of 



132 Suppuration and Abscess 

greatly attenuated virulence or because the local vital resistance is at a high 
level to these bacteria. Inflammation occurs, there is copious exudate and 
enormous amounts of fibrous tissue form. 

Wooden phlegmon is occasionally found in syphilitics and is most apt to 
arise in those in poor health. It is frequently mistaken for sarcoma or car- 
cinoma, in fact Lange believes it to be cancer. Wooden phlegmon is always 
dangerous and is frequently fatal. 

Treatment. — Extirpation is not feasible and the surgeon instead makes nu- 
merous incisions and usually dresses with an antiseptic poultice. In these cases 
free suppuration occasionally occurs after a long delay and when it does occur 
a cure may promptly follow evacuation. If free suppuration were induced 
to occur by inoculations the effect might be favorable. In view of the diffi- 
culties, dangers, and great prolongation of these cases it is desirable that 
staphylococcic suppuration ensue upon the multiple incisions and it is justi- 
fiable to secure this by direct inoculation, or, better, by making multiple in- 
cisions and applying old-fashioned flaxseed poultices. 

Acute Abscesses. — An acute abscess is a circumscribed cavity of new for- 
mation containing pus. We emphasize the fact that it is a circumscribed cavity 
— circumscribed by a mass of leukocytes and proliferating connective-tissue 
cells. A purulent infiltration is not circumscribed, hence it does not consti- 
tute an abscess. An essential part of the definition is the assertion that 
the pus is in a cavity of new formation, in an abnormal cavity; hence pus in 
a natural cavity (pleural, pericardial, synovial, or peritoneal) constitutes a 
purulent ejjusion, and not an abscess, unless it is encysted in these localities 
by walls formed of inflammatory tissue. 

An acute abscess is due to the deposition and multiplication of pvogenic 
bacteria in the tissues or in inflammatory exudates. These bacteria attack 
exudates or tissues, form irritants which cause inflammation or intensify 
existing inflammation, and by exerting a peptonizing action on intercellular 
substance and the fibrin of the exudate liquefy tissue and the products of 
inflammation, and form pus. As a rule, within twenty-four hours after 
lodgment of the bacteria the exudation increases in amount, the migrated 
leukocytes gather in enormous numbers, the fibers of tissues swell, and the 
connective-tissue spaces distend with cells and fluid. The connective-tissue 
cells, acted on by pus cocci, multiply by karyokinesis, develop many nuclei, 
lose their stellate projections, degenerate, and constitute one form of pus- 
corpuscle, leukocytes forming the other. All the small vessels are choked 
with leukocytes, this blocking serving to cut off nourishment and tending to 
produce anemic necrosis. Liquefaction occurs at many foci of the inflam- 
mation, drops of pus being formed, the amount of each being progressively 
added to and many foci coalescing (Fig. 68). The pus-cavity is circumscribed, 
not by a secreting pyogenic membrane, but by a mass of fibroblasts, whose 
cells and intercellular material have not as yet broken down; such a mass of 
fibroblasts is often called embryonic tissue, and it is circumscribed by a zone 
of inflammation in which there are hordes of migrated leukocytes (Fig. 69). 
As an abscess increases in size, the embryonic tissue from within outward 
liquefies into pus, and the zone of inflammation beyond continually enlarges 
and forms more embryonic tissue. After a time the inflammation reaches 
the surface, the embryonic tissue glues the superficial to the deeper parts, the 



Acute Abscesses 



1 33 



superficial part inflames and becomes embryonic tissue, and the intercellular 
substance is liquefied. When pus has all but reached the surface, a thin layer 
of tissue only being undestroyed, an elevation or tit of thin tissue is formed, due 
to the fluid pressure. This process is known as pointing. The elevation or 




Fig. 68. — Infiltration of connective tissue of cutis (X 500) with beginning suppuration in the center 

(Senn). 



point thins from tension and liquefaction, and finally gives way and spon- 
taneous evacuation occurs. When an abscess forms in an internal organ or in 
some structure which is not loose, like connective tissue, — for instance, in a 
lymphatic gland, — a mass of pyogenic bacteria, floating in the blood or 
lymph, lodges, and these bacteria by means of irritant products cause coagu- 
lation necrosis of the adjacent tissue and 
inflammatory exudation around it. The 
area of coagulation necrosis becomes filled 
with white blood-cells, and the dry ne- 
crosed part is liquefied by the cocci. 
Suppuration in dense structures causes 
considerable masses of tissue to die and to 
be cast off, and these masses float in the 
pus. Death of a mass with dissolution of 
its elements is necrosis, or inflammatory 
gangrene. Pus travels in the line of least 
resistance. It may reach a free surface, 
or may break into a cavity or joint, may 
invade bone or destroy a vessel. When 
an abscess ceases to spread or is evacu- 
ated, the fibroblastic layer forming the 
walls becomes vascularized and is con- 
verted into granulation tissue. An abscess heals by the collapse of its walls and 
fusion of the granulations (union by third intention), or by granulation (union 
by second intention). In either case granulation tissue is ultimately con- 
verted into fibrous or scar tissue. 




Fig. 69. — Diagram of an abscess : A. 
pus: B. layer of fibroblasts ; C, tissue in- 
filtrated with leukocytes : D. zone of sta- 
sis ; E, zone of active hyperemia ; F, 
healthv tissue. 



134 Suppuration and Abscess 

Forms of Abscesses. — The following are the various forms of ab- 
scesses: Acute, which follows an acute inflammation. Strumous, cold, lym- 
phatic, tuberculous, or chronic abscess is due to the bacilli of tuberculosis and 
does not contain true pus unless there is secondary pyogenic infection. It pre- 
sents no signs of inflammation. A lymphatic abscess may form in a week or 
two, and hence is not necessarily chronic, which term is properly applied to a 
pyogenic infection of an infective granuloma. Caseous or cheesy abscess, a 
cavity containing thick cheesy masses, is due, perhaps to the fatty degenera- 
tion of inflammatory exudate and pus-corpuscles, but most commonly results 
from the caseation of a tuberculous focus. Circumscribed abscess is one limited 
by a layer of fibroblasts. Diffused abscess is an unlimited collection of pus, in 
reality not an abscess, but either a purulent effusion or a purulent infiltration. 
Congestive, gravitative, wandering, or hypostatic abscess is a collection of pus 
or tuberculous matter which travels from its formation-point and appears at 
some distant spot (as a psoas abscess). Critical or consecutive abscess is one 
which arises during an acute disease. Diathetic abscess finds its predisposing 
cause in a diathesis. Embolic abscess is due to an infected embolus. Tym- 
panitic or emphysematous abscess is one which contains air or the gases of 
putrefaction. Encysted abscess, in which pus is circumscribed in a serous 
cavity. Fecal or stercoraceous abscess is one containing feces in consequence 
of a communication with the bowel. Follicular abscess is one arising in a 
follicle; hematic abscess, one arising around blood-clot, as a suppurating hema- 
toma; marginal abscess, which appears upon the margin of the anus. Pyemic 
or metastatic abscess is the embolic abscess of pyemia. Milk abscess is an 
abscess of the breast in a nursing woman. Ossifluent abscess arises from 
diseased bone. Psoas abscess is a tuberculous abscess arising from vertebral 
caries, the matter following the psoas muscle, and usually pointing in the groin. 
A sympathetic abscess, arising some distance from the exciting cause, such as a 
suppurating bubo from chancroid, is not in reality sympathetic, because in- 
fective material has been carried from the primary focus. Thecal abscess is a 
purulent effusion in a tendon-sheath. Tropical abscess is an abscess of the 
liver, so named because it occurs chiefly in those dwelling in tropical countries: 
it usually follows dysentery; urinary abscess, caused by extra vasated urine. 
A verminous abscess is one which contains intestinal worms and communicates 
with the bowel. A syphilitic abscess occurs in the bones during tertiary 
syphilis, and is gummatous and not pyogenic. Brodie's abscess is a chronic 
abscess of the bone, most common in the head of the tibia. A superficial ab- 
scess occurs above the deep fascia; a deep abscess occurs below the deep 
fascia. A residual or Paget' s abscess is a recurrence of active changes, it may 
be after years, around the residue of a former tuberculous abscess. 

Symptoms of Acute Abscess.— In an acute abscess, as before stated, a 
part becomes inflamed and a quantity of fibroblasts are formed; fibroblastic 
tissue is liquefied (as above noted) and pus is produced. An acute abscess can 
occur in a person of any constitution. 

Local Symptoms. — Locally there is intensification of inflammatory 
signs and enormous increase of the swelling. At first the area is hard, but 
afterwards becomes soft, and it finally fluctuates. The discoloration becomes 
dusky. The pain becomes throbbing and the sense of tension increases. 
The pain is greater the more dense the implicated tissue and the greater 



Acute Abscesses in Various Regions 135 

the number of nerves it contains. At every pulse-beat the tension in the 
abscess increases temporarily, and hence the pain momentarily increases. 
Pain is increased by a dependent position of the part. There is great tender- 
ness. The pain may be felt at the seat of suppuration or may be referred to 
some distant point. Tenderness is located at the focus of disease. The cuta- 
neous surface, if the abscess is adjacent, is seen to be polished and edematous, 
and after a time pointing is observed and fluctuation can be detected. If pus 
is deeply situated the skin may not be reddened and perhaps the area of in- 
duration cannot be palpated. In such a case there is often rigidity of the 
muscles overlying the abscess (as in abdominal suppurations), the skin may 
be edematous (as in some cases of empyema), and besides local pain there 
may be pain due to pressure upon a nerve trunk, the pain perhaps being re- 
ferred to a distant point. 

Constitutional Symptoms. — If there is a small collection of pus in an 
unimportant structure there may be no obvious constitutional disturbance. 
If the abscess contains much pus or affects an important part, disturbances 
generally appear, from slight rigors or moderate fever to chills, high tempera- 
ture, and drenching sweats. The constitutional condition typical of an ab- 
scess is due to the absorption of retained toxins, and is known as "suppurative 
fever." When an abscess is open but ill-drained, or when it is unopened 
and deep-seated, long-continued suppuration causes a fever which is markedly 
periodic: the temperature rises in the evening, attaining its highest point 
usually between 4 and 8 p. m., and sinks to normal or nearly normal in the 
early morning (from 4 to 8 A. 11.). When the temperature begins to fall, pro- 
fuse perspiration takes place. This fever is known as hectic. Prolonged 
suppuration causes albuminoid changes in various organs, notably in the liver, 
spleen, and kidneys. Albuminoid changes are especially common when there 
has been mixed infection of a tuberculous area and long-continued suppura- 
tion. It also occurs as a result of syphilis. 

Dr. J. C. DaCosta, Jr., tells us ("Clinical Hematology") that "in both 
trivial and extensive pus foci the number of leukocytes may be normal or even 
subnormal; in the former instance because systemic reaction is not provoked, 
and in the latter because it is overpowered. Leukocytosis may also be absent 
in case toxic absorption is impossible, owing to the complete walling off of 
the abscess. In all other instances save these, a definite and usually well- 
marked leukocytosis occurs, amounting on the average to a count of about 
twice the mean normal standard, but frequently greatly exceeding this figure 
in the individual case." 

The signs and symptoms of an abscess are somewhat modified by location, 
and it is wise to discuss acute abscesses in different situations. 

Acute Abscesses in Various Regions.— Abscess of the brain may 
follow cerebral concussion or fracture of the skull may arise during a general 
infection but in about 50 per cent, of cases results from chronic suppurative 
disease of the middle ear. In abscess of a silent region of the brain svmptoms 
may long be entirely absent. The usual symptoms are a temporarv initial rise 
of temperature which soon gives place to a normal and in one-half of the cases 
to a subnormal temperature, headache, vomiting, delirium, drowsiness, and 
choked disk. Localizing symptoms, spasmodic or paralytic, may be present. 
There is usually leukocytosis. In but few cases are there elevated tempera- 



136 Suppuration and Abscess 

ture and sweats. Toward the end of the case there may be elevated tempera- 
ture and delirium. In extradural abscess there is fever from beginning to end 
(page 720). 

Appendiceal or appendicular abscess results from inflammation, usually 
but not always with perforation of the vermiform appendix, plastic peritonitis 
leading to agglutination of the mesentery and omentum, adhesion of the bowels 
and mesentery, and the formation of a barrier of leukocytes and a mass of fibro- 
blasts. This process circumscribes the pus. If the pus in suppurative ap- 
pendicitis has been formed by colon bacilli or staphylococci, it will probably 
be circumscribed and limited. If the pus has been formed by streptococci, 
it will probably not be limited, and the peritoneum will be attacked by diffuse 
septic peritonitis. The signs of appendicular abscess are pain, tenderness, 
muscular rigidity, the existence of a mass, which may be palpated through the 
abdominal wall or rectum and which is dull on percussion, vomiting, sometimes 
constipation, and sometimes diarrhea. Very seldom is there skin edema and 
fluctuation. The patient lies upon his back, usually with one or both thighs 
flexed. In appendicular abscess there is fever, usually higher at night than 
in the morning, profuse sweating occurring during the fall. In some cases 
the temperature is peristently high. In some the elevation is trivial. In 
some chills occur. A sudden fall of temperature with shock is produced by rup- 
ture of the abscess-wall. If this accident happens, general peritonitis quickly 
arises. In appendicular abscess there is marked leukocytosis unless the walls 
are very thick or unless the process has diffused and general peritonitis has 
taken place, in which conditions it may be absent. Appendiceal abscess may 
be assumed to exist when the symptoms of appendicitis persist after the fifth 
or sixth day, or when, after the symptoms have subsided, they reappear a day 
or two later (page 853). 

Abscess of the liver may not be announced by symptoms until rupture. 
It may follow dysentery, may be a result of the lodgment of infected 
clots from the hemorrhoidal veins, may follow upon the infective phlebitis of 
appendicitis, may result from septic cholangitis or suppuration of a hydatid 
cyst. We usually find fever of an intermittent type, profuse sweats, pain in 
the back, the right shoulder, or the right hypochondriac region, enlargement 
of the area of liver-dulness, also hepatic tenderness, and finally constitutional 
symptoms of the existence of pus. Sometimes there are fluctuation and skin 
edema over the liver, and the general cutaneous surface may be a little jaun- 
diced. The symptoms vary as the pus invades adjacent organs. When there 
are pain on respiration and evidences of diaphragmatic pleuritis the pus is prob- 
ably breaking into the pleural sac. There may or may not be leukocytosis 
(seepage 877). 

Deep Abscess of the Neck. — The majority of these abscesses are due to 
suppuration of lymph glands, bacteria having reached the glands from an ad- 
jacent area of infection, cutaneous, mucous, or osseous. Suppuration beneath 
the deep fascia induces great pain and extensive swelling and often interfer- 
ence with respiration. The constitutional evidences of suppuration are noted. 
Acute suppuration under the deep fascia of the submaxillary region 
causes extensive inflammatory edema, interference with respiration and 
deglutition, violent constitutional symptoms, and often sloughing of tissues 
(see Ludwig's "Angina"). A deep abscess over the carotid artery is lifted 



Acute Abscesses in Various Regions 137 

by each arterial beat and may be mistaken for aneurysm, but the pulsation is 
not expansible. The pus of a deep cervical abscess may track its way into the 
mediastinum or axilla or the abscess may break into a large blood-vessel, the 
pharynx, the wind-pipe or the gullet. 

Axillary Abscess. — Superficial abscesses are usually multiple, are in reality 
furuncles, and result from infection of the sweat glands and hair follicles. 

Deep abscesses are in most instances due to suppuration of the axillary 
lymph-glands. The most common cause is an infected wound or a focus of 
suppuration about the hand, forearm, arm or chest. An axillary abscess may 
result from caries of a rib or may follow a deep cervical abscess. An axillary 
abscess may be lifted at each beat of the artery and to this extent it resembles 
an aneurysm, but the pulsation is not expansile. 

Acute retropharyngeal abscess is due to pyogenic infection of the retro- 
pharyngeal tissues. The abscess usually forms upon one of the lateral halves 
of the pharynx. It may be due to traumatism, to acute infectious diseases, 
to infective processes of the mucous membrane of the mouth, ear, and naso- 
pharynx, or to pyogenic infection of a tuberculous abscess. In the great ma- 
jority of cases the disease is due to suppuration of the deep cervical glands. 
There is pain, difficulty in swallowing, dyspnea, nasal voice, bulging into the 
pharynx, which is detected by inspection and palpation, enlargement of the 
deep cervical glands, fever, sweats, and great weakness. Tuberculous retro- 
pharyngeal abscess is considered on page 151. 

Subphrenic or subdiaphragmatic abscess is apt to begin beneath the diaph- 
ragm, though in some few instances the pus forms above this muscle, and 
subsequently gains access to the region beneath. Such an abscess may con- 
tain not onlv pus, but gas, and in some cases also fluid from the stomach or 
intestine. The gas of a subphrenic abscess may have entered from a perfora- 
tion of a hollow viscus or may have been made by gas-forming bacteria. Sub- 
phrenic abscess may arise after perforation of the bowel or stomach, or it may 
result from Pott's disease, perinephric abscess, traumatism, abscess of liver, 
kidney, spleen, or pancreas, empyema or pneumonia (Greig Smith) . The symp- 
toms are pain, fever, sweats, dyspnea, cough, and the physical signs of a collec- 
tion of fluid beneath the diaphragm and often of gas in the cavity of the abscess. 
As in any other abscess there may or may not be leukocytosis (page 135). 

Abscess of the lung gives the physical signs of a cavity; the expectoration is 
offensive and contains fragments of lung-tissue. An abscess may occasionally 
be located by the use of the x-rays. Pyemic abscesses may exist and yet escape 
discovery. (See Surgery of Respiratory Organs.) 

Abscess of the mediastinum may arise secondary to deep abscess of the neck 
or vertebral suppuration ; suppuration of the mediastinal glands, lung or pleura ; 
caries of a rib or of the sternum, ulceration of the esophagus or pericarditis. It 
causes throbbing retrosternal pain, pain in the back, chills, fever, sweats, 
irregular pulse, and often dyspnea. A lump may appear which pulsates and 
fluctuates, but the pulsation is not expansile. 

Perinephric abscess usually causes tenderness and pain in the lumbar 
region or about the hip-joint, which pain runs down the thigh and is accom- 
panied by retraction of the testicle. Induration, fluctuation, or edema of the 
skin may be observed in the lumbar region. The constitutional symptoms of 
suppuration usually exist (page 135). 



138 Suppuration and Abscess 

Abscess or empyema oj the antrum of Highmore is a collection of pus within 
che maxillary antrum. It results from inflammation of the jaws, the teeth or 
the mucous membrane of the nose. It causes pain, edematous swelling of the 
overlying soft parts, and crepitation on pressure upon the superior maxillary 
bone. Pus may escape from the nostril of the diseased side when the head 
is bent in the direction of the healthy side. A rhinoscopic examination dis- 
closes the fluid passing into the nares. The antrum on the side of the abscess 
cannot be transilluminated by an electric light in the mouth (Garel's sign). 
The constitutional symptoms of suppuration usually arise. 

Alveolar abscess is suppurative dental periostitis due to diseased teeth. 
The simplest form is a gum-boil, a collection of pus between the gum and the 
bone "external to the root of the tooth which is the seat of inflammation" 
("Dental Surgery," by Sewill). In more severe cases the suppuration begins 
within the tooth socket and the pus escapes around the neck of the tooth, a dis- 
tinct and local abscess may be situated at the end of the root, absorption of 
bone having occurred, or a considerable cavity may form in the bone, the ex- 
ternal maxillary plate being perforated. In the very severe cases the cheek is 
involved. An alveolar abscess may break through the gum into the mouth or 
it may break externally through the cheek. Alveolar abscess causes intense 
pulsatile pain, marked swelling of the gum and cheek, and sometimes very 
great edematous and dusky swelling of the face. A sinus may follow its 
evacuation. Dead bone may form. 

Abscess oj the larynx invariably causes laryngeal edema which obstructs 
respiration and puts life in jeopardy. Such an abscess is most apt to appear 
upon the oral surface of the epiglottis but may arise within the larynx. It in- 
duces violent cough, pain, interference with the voice, swallowing, and 
breathing, and the swelling can often be felt with a finger and can always be 
seen by the aid of a laryngoscope. 

An ischiorectal abscess is situated in the areolar tissue of the ischiorectal 
fossa. The pyogenic organisms usually gain entrance to the lymphatics by 
way of an abrasion, fissure, or ulceration of the rectum or anus. A perfora- 
tion made by a foreign body may inaugurate the condition. In rare cases 
bacteria reach the fossa in the blood-stream. The pain is severe and throbbing; 
there are great tenderness, redness and edema of skin, induration, and usually 
the constitutional symptoms of pus-formation. Fluctuation is a very late 
sign because of the density of the fascia. 

Prostatic abscess may result from catheter infection, from infection of the 
bladder or urethra, or from traumatism, but the commonest cause is gonorrhea. 
There may be one abscess, several abscesses, or multiple abscesses. Pus may 
break into the rectum, the bladder, or the urethra or may break externally. 
A prostatic abscess is manifested by chills, fever, sweats, frequency of mic- 
turition, tenderness of the perineum and rectum, and agonizing pain, develop- 
ing during an attack of acute prostitis. A finger in the rectum can palpate 
the swollen gland. 

Abscess oj the breast follows absorption of pyogenic bacteria from a 
fissure or abrasion of the nipple. Some surgeons maintain that the bacteria 
enter along the milk-ducts, while others assert that they gain entrance by the 
lymphatics, It is most common in nursing women. Its symptoms are 
swelling, tenderness, pulsatile pain, dusky discoloration, skin edema, fluctua- 
tion, and usually constitutional disorder. (See Mastitis.) 



Diagnosis of Abscess 139 

Orbital abscess is a diffuse suppuration due to cellulitis or a collection of 
pus due to caries or necrosis of the orbital wall, suppuration of the accessory 
nasal sinus, facial erysipelas, or dental caries. In severe orbital cellulitis 
the movements of the eye are limited, the lids are very red and edematous, 
the conjunctiva is red and swollen (chemosis), and, if the case is not promptly 
relieved, optic neuritis may arise and sloughing of the cornea occur. 

Von Bezold's Abscess. — In this condition the pus of a suppurating mastoid 
process breaks through the mastoid near the tip and enters into the sheath of 
the digastric muscle or the sheath of the sternocleidomastoid. There exist ex- 
tensive inflammatorv swelling of the neck, a history of mastoid trouble, usually 
a lessened amount of pus from the ear, pain in the neck and constitutional 
symptoms. The condition suggests thrombosis of the lateral sinus, but the 
symptoms are not so violent and are not pyemic as they are in that disease. 

Abscess oj the Groin or Pyogenic Bubo. — Such an abscess may have mounted 
up from the pelvis, tracked forward from the sacro-iliac joint, or descended in 
the psoas sheath from the vertebra?, but in a very great majority of cases it is 
due to suppuration of the lymphatic glands. A bubo may be tuberculous, 
venereal or pyogenic. A pyogenic bubo results from an area of infection in 
the trajectory drained by the lymph-vessels of the inguinal or femoral glands. 
The glands involved may be superficial or deep. The symptoms are those 
ordinarily linked with suppuration. Occasionally the pulsations of the great 
vessels may lift the mass. 

Abscess of the Popliteal Space. — This results from traumatism, mixed in- 
fection of a tuberculous or syphilitic area, suppuration of the contained lymph- 
glands of one of the adjacent bursa? or of the neighboring bone. In rare 
cases it arises as a result of suppuration of the sac of an aneurysm. The 
symptoms are severe pain, swelling, flexion of the knee, and edema of the leg. 
The pulsations of the popliteal artery may be transmitted to the abscess. 
These pulsations are not expansile, as in aneurysm. Pus may pass under 
the deep fascia up or down the extremity, or may break into the knee-joint. 

Suppurative thccitis or felon is a form of diffuse suppuration. (See Felon.) 

Palmar abscess is a purulent effusion (page 645). 

Furuncle and carbuncle are discussed on pages 1056 and 1057. 

Empyema is a purulent effusion into the pleural sac (page 773). It is 
technically an abscess if it becomes encapsuled. 

Diagnosis. — The diagnosis of an abscess rests upon — (1) its history; (2) 
fluctuation; (3) pointing; (4) surface edema; (5) the use of the tubular ex- 
ploring needle; and (6) leukocytosis. 

Fluctuation is the sensation imparted to a finger held against a sac con- 
taining fluid when a wave is started in the fluid by striking the mass with a 
finger of the other hand. Fluctuation cannot be obtained if the amount of 
fluid is small. It should never be sought for across a limb, but rather along it, 
because a false sense of fluctuation can always be obtained across the muscles 
of the limb. Pointing and surface edema have been discussed. 

A suspected abscess in a part containing large blood-vessels under no cir- 
cumstance should be opened by a bistoury without knowing that the diagnosis 
is certainly correct. This knowledge is obtained in some cases by inserting 
a small aspirating needle and observing the nature of the fluid which exudes. 
This operation must be performed with aseptic care; otherwise, if there is no 



140 



Suppuration and Abscess 



abscess, infection may be inaugurated; if there is an abscess, mixed infection 
may occur. The older operators used a grooved exploring needle, but many 
able surgeons object to its use on the ground that when plunged into an in- 
fected area, pus bathes the track of penetration and may cause infection of 
other tissues and diffusion of the pyogenic process. The tubular exploring 
needle is the proper instrument. 

An abscess which moves with the pulse because it rests upon an artery 
may be confounded with an aneurysm. The pulse movements of such an 
abscess are in one direction only; the abscess is lifted with each pulse-beat; 
but does not enlarge, and if a finger is laid upon either side of it the fingers 
will be lifted, but not separated. The pulse movements of an aneurysm are 
in all directions; they are expansile, the tumor grows larger, and the fingers 
will not only be lifted, but will also be separated. The small tubular exploring 
needle may be used in doubtful cases; if aseptic, it will do no harm even to an 
aneurysm. A rapidly growing, small-cell sarcoma feels not unlike an abscess, 
but the exploring needle discovers blood, and not pus. A cystic tumor is 




Fig. 70. — Vischer's case for carrying culture-tubes for inoculation. 



separated from an abscess by the absence of inflammation, or, if it inflames, 
by the nature of the contained fluid. Ordinary caution will prevent one con- 
founding an abscess with strangulated hernia. A tuberculous abscess is sepa- 
rated from an acute abscess by the absence of inflammatory signs in the 
former. The contents of the acute abscess differ from those of the tuberculous 
abscess. When an abscess exists in an important region (brain, appendix, 
liver, etc.), cultures of the pus should be taken after incision. Such studies 
often give valuable information as to the probable course of the condition, 
and an accumulation of many accurate observations will add greatly to 
scientific information. Fig. 70 shows a convenient case for carrying cul- 
ture-tubes. 

Prognosis. — The prognosis varies according to the number of abscesses, 
their location and size, the strength of the patient, and the virulence of the 
causative bacteria. 

Treatment. — In the treatment of an abscess there is one absolute rule 
which knows no exception, namely, that whenever and wherever pus is found 



Treatment of Abscess 141 

the abscess should be evacuated at once, and, after evacuating it, thorough 
drainage must be provided for. It should be opened early, if possible even 
before fluctuation and positively before pointing, to prevent tissue destruc- 
tion, sub-fascial burrowing, and general contamination. Drainage is continued 
until the discharge becomes scanty, thin, and seropurulent. 

Alveolar abscess requires prompt incision through the gum, extraction of 
the diseased tooth in most cases, and the rinsing of the mouth at frequent 
intervals with hot fluid. Heat should not be applied externally, as it would 
favor external rupture. If spontaneous rupture externally is inevitable, then 
an incision must be made at the point where the abscess is nearest the sur- 
face. The cut will leave less scar than will spontaneous evacuation. It is 
sometimes necessary to gouge a line through the external table of the bone, 
pus being lodged within the two osseous plates. 

Abscess of the liver, if the liver is adherent to the parietal peritoneum, is 
opened at one operation; if the liver is not adherent, the abscess is often 
operated upon in two stages. In the two-stage operation an incision is 
made along the edge of the ribs down to the liver, which organ is then stitched 
to the edges of the wound. In a day or two after the first operation the two 
layers of peritoneum are firmly adherent and the abscess can be opened with- 
out danger of the passage of pus into the peritoneal cavity. The abscess, 
located by an aspirating needle, is opened by the Paquelin cautery, is washed 
out with salt solution, and a tube is inserted. If care is taken the operation 
can be safely completed in one seance even if the liver is not adherent to 
the parietal peritoneum. If this course is determined on, after the 
liver is exposed by incision, the exposed surface of the organ is surrounded 
with iodoform gauze, the abscess is located by an aspirating needle, is opened 
by the cautery, is irrigated and drained as directed above. Some physicians 
try to locate an abscess by plunging an aspirating needle into the liver before 
making an incision. This procedure seems to me uncertain and dangerous. 

Abscess of the dome of the liver may be reached by resecting a rib, in- 
cising the pleura, and opening through the diaphragm (transthoracic hep- 
atotomy). 

Abscess of the mediastinum, like all other abscesses, requires incision and 
drainage. This is effected, if the abscess can be reached from in front, by 
cutting between the rib cartilages or by trephining the sternum. Abscess of the 
posterior mediastinum can be reached only by resecting portions of several ribs 
near their vertebral ends. 

In abscess of the lung an incision is made and the pleura is exposed. The 
incision is usually through an intercostal space; but if the spaces are narrow, 
it will be necessary to resect a rib. If the two layers of pleura are found 
adherent, the operation is proceeded with. If they are not adherent, they are 
stitched together with catgut sutures, and the surgeon waits fortv-eight hours 
before continuing. This precaution is taken in order to prevent collapse 
of the lung from acute traumatic pneumothorax, during operation. The 
operation is completed by locating the pus by means of an aspirating needle, 
evacuating it by the cautery at a dull-red heat, and inserting a drainage-tube 
into the abscess-cavitv. 

A subphrenic abscess requires operation at once. Immediatelv before oper- 
ating, if in doubt, it may be justifiable to endeavor to locate pus with an aspi- 



142 Suppuration and Abscess 

rating needle. Incise the abscess and open any secondary abscesses. Many 
cases point below the diaphragm and are easily reached by an incision in the 
loin or in the epigastric region. Lannelonge resects the eleventh and 
twelfth ribs and raises the pleura out of the way. Some surgeons prefer to 
practice rib resection and incise the adherent pleural layers and the diaph- 
ragm. After drainage has been continued for a time it may be neces- 
sary to do a secondary operation in order to cure the lesion causative of the 
abscess, for instance, it may be necessary to close a gastric perforation. 

In abscess of the antrum 0} Highmore bore a gimlet-hole through the supe- 
rior maxillary bone, above the canine tooth, or perforate the bone by means of 
a trocar. Irrigate daily with boiled water or normal salt solution. Keep 
the opening from contracting by inserting a small tent of iodoform gauze. In 
persistent cases it may be necessary to draw a tooth, break through the socket 
of the first or second bicuspid into the antrum, and insert a silver or hard- 
rubber tube, and also to perforate the antrum from the inferior meatus and 
keep the opening patent. In very persistent cases osteoplastic resection of a 
portion of the upper jaw will be demanded. 

In appendicular abscess incise, support the abscess-walls with gauze, 
remove the appendix in most cases, but not in all, and insert a drainage-tube 
and strands of gauze (page 864). 

An ischiorectal abscess must be opened early. The surgeon never waits 
for fluctuation. Fluctuation is a very late symptom. To wait for it entails 
great destruction of tissue and serves no useful purpose. Place the patient 
on his side, with the legs drawn up. Insert a finger in the rectum, lift the 
abscess toward the surface, and incise it from the surface. The incision runs 
from the anal margin like a spoke from the hub of a wheel. Irrigate with 
salt solution, inject iodoform emulsion, insert a drainage-tube, dress, and let 
the patient know he is in danger of developing a fistula. 

A retropharyngeal abscess must be opened early because delay may 
lead to fatal obstruction and because if spontaneous evacuation occurs the 
patient may be suffocated. Some surgeons open it from within the mouth, 
but this exposes the patient to the danger of septic bronchopneumonia from 
inhalation of purulent elements and to serious gastro-intestinal disorder from 
swallowing quantities of pus. Again, if opened through the mouth, the 
abscess is liable to become putrid. It is better to open it from the neck 
by Hilton's method, the incision being carried through the sternocleidomas- 
toid muscle or posterior to it. Drainage is inserted and the abscess treated 
in the usual way. 

In abscess of the breast make an incision radiating from the nipple, or, what 
is better, incise under the breast by means of a cut at the inferior thoracic 
mammary junction, and enter the abscess from beneath. 

In abscess of the brain the skull should be trephined, the membranes incised, 
and the abscess sought for, opened, and drained (page 718). 

In suppuration within the orbit due to cellulitis, incise from the conjunctiva 
and drain. In suppuration due to caries or necrosis of the upper orbital wall 
make a transverse incision through the upper lid, reach the pus by Hilton's 
method (page 144), remove carious or loose necrotic bone, and drain. 

A perinephric abscess requires an incision in the lumbar region and free 
drainage. 



Treatment of Abscess 143 

An abscess oj the larynx requires immediate scarification and inhalation 
of steam to abate swelling. In a severe case the surgeon should at once per- 
form tracheotomy. 

Bezold's abscess requires one or more incisions in the neck for drainage. 
Then the mastoid is exposed, its tip, including the osseous fistula, is removed, 
and its interior is cleared out by a complete operation. 

A prostatic abscess should be opened promptly by a perineal incision. 

In an ordinary superficial abscess, after cleansing the parts, make the skin 
tense, locate the superficial vessels and nerves, and plan the incision to avoid 
them. Incise with a sharp-pointed curved bistoury at the most dependent 
part of the abscess or through the region of pointing. If the abscess is upon 
the face or neck, make the incision in the line of the skin creases so as to limit 
the scar. The incision must not be made suddenly and fiercely, neither should 
it be made with hesitation and uncertainty. As Bryant says: "It should be 
done, as ought every other act of surgery, with confidence and decision, bold- 
ness and rapidity of action being governed by caution and made subservient 
to safety'' (Bryant's " Practice of Surgery"). Permit the pus to run out spon- 
taneously; pressure, as a rule, is undesirable because it may damage the ab- 
scess-wall and cause diffusion of the infection. If tissue shreds block 
the opening, they must be picked out with forceps. If the atmospheric 
pressure will not cause the pus to flow out, make light pressure with warm, 
moist, aseptic gauze pads. After the pus has come away gently wash the cav- 
ity with normal salt solution or boiled water, and drain with a tube for two or 
three days, when the discharge becomes serous. It is not desirable to overdis- 
tend the abscess-cavity with fluid, because the hydrostatic pressure might break 
down the wall of young cells and infection be diffused. Do not irrigate with 
powerful disinfectants. They cannot be used strong enough to really disin- 
fect, but may easily be used strong enough to cause necrosis of an abscess- 
wall. Peroxid of hydrogen is not to be used unless the incision is large, 
because the gas it generates may tear the abscess-wall and diffuse the infection. 
Peroxid of hydrogen is a dangerous agent to inject into the cavity of a deep 
abscess of the neck, as the liberated gas may not escape from the opening, but 
may pass widely into the tissues and cause great distention. The author saw 
a child who narrowly escaped death after such an injection. In this patient 
the gas passed beneath the pharyngeal mucous membrane and the swelling 
almost occluded the air-passages. If an abscess contains putrid pus the in- 
cision should be free and after evacuation it should be irrigated with hot salt 
solution or peroxid of hydrogen and injected with iodoform emulsion. Pursue 
rigid antisepsis in dealing with purulent areas. It is true we already have infec- 
tion with pyogenic bacteria, but infection can also take place with organ- 
isms of putrefaction, causing pus to become putrid, or with other bacteria, 
for instance those of tetanus. If a tube is not used and the cavity is packed 
with iodoform gauze, remember that gauze will not drain pus and requires 
to be changed once a day or oftener. An abscess should be dressed with 
hot, moist antiseptic dressings (antiseptic fomentation) and the part must 
be put at rest. When the discharge becomes thin and scanty, dry aseptic or 
antiseptic dressings are used. 

In a deep abscess or an abscess situated near important vessels, do not 
boldly plunge in a knife. Hilton says to "plunge in a knife is not courageous,. 



144 Suppuration and Abscess 

as it is without danger to the surgeon, but may be fatal to the patient. " Re- 
member also that a large amount of pus displaces normal anatomical relations. 
Hilton's method of opening a deep abscess (as in the axilla or neck) is to cut 
to the deep fascia, nick the fascia with a knife, and then push into the abscess 
a grooved director until pus shows in the groove; along the groove push a pair 
of closed dressing forceps; after they reach the depths take out the director, 
open the forceps, and withdraw them while open, and so dilate the opening; 
then insert a tube and gently irrigate with warm salt solution. 

Always endeavor to open an abscess at its most dependent part, remem- 
bering that the situation of this part may depend upon whether the patient is to 
be erect or recumbent. If we do not make the opening at the lowest point, all 
the pus will not run out and the walls will not completely collapse. A deep 
abscess must be drained thoroughly until the discharge becomes seropurulent. 
When the tube is removed it is wise to insert a tent of iodoform gauze just 
through the outlet of the abscess. This tent prevents the skin from closing 
over the channel. It is removed and a new one inserted every day until it is 
clear that there is no longer danger of fluid becoming blocked and retained. 
When an abscess contains diverticula or pouches they should be slit up or a 
counter-opening ought to be made. A counter-opening is made by entering 

the dressing forceps at the first in- 
cision, pushing them through the 
abscess to the point where we wish 
to make our counter-opening, 
opening the blades, and cutting 
between them from without in- 
ward. The blades are then closed 
and projected through the incision; 

Fig. 71— Drainage-tubes for abscess requiring irri they are opened in order to dilate 

the new door, and are closed again 
upon a drainage-tube, which is pulled through from opening to opening 
as the instrument is withdrawn. When pus burrows, insert a grooved 
director in each channel and slit the sinus with a knife. An abscess may 
make an opening through dense fascia, the opening being small like the 
neck of an hour-glass (shirt-stud abscess). Always examine to see if such 
a condition exists, and if it is found, incise the fascia. 

In a deep abscess containing putrid pus, frequent irrigation is desirable. 
In such a case two tubes may be employed (Fig. 71). The tubes are pre- 
vented from slipping in by the use of a safety-pin (a). The irrigating fluid is 
passed into the cavity (d) through the tube b, which is without fenestra, and it 
runs out through the tube c, which possesses fenestra. 

Rest is of the first importance in the healing of an abscess, and we try to 
obtain it by bandages, splints, and pressure, which will immobilize adjacent 
muscles and approximate the abscess- walls. If an abscess is slow to heal, use 
as a daily injection a solution of corrosive sublimate of the strength of 1 : 1000, 
or three drops of nitric acid to § j of water, or 3 grains of zinc sulphate to § j 
of water, or a 5 per cent, solution of carbolic acid, or a 2 per cent, aqueous 
solution of pyoktanin, or 20 drops of tincture of iodin to § j of water, or a very 
dilute solution of bichlorid of palladium. The constitutional treatment of an 
abscess depends upon the severity of the morbid process and the importance 




Tuberculous Abscess 145 

of the structures involved. In a serious case the patient should be put to 
bed, opiates should be given with a free hand, the bowels be kept active by- 
calomel and salines, skin activity be maintained, the taking of nutritious food 
insisted on, and stimulants liberally employed. 

Purulent Effusions. — (See Suppurative Thecitis, Palmar Abscess, Sup- 
purative Synovitis, Purulent Peritonitis, Empyema, etc.) 

Tuberculous Abscess. — The tuberculous abscess is called, also, the 
cold, the lymphatic, the congestive, the scrofulous, the strumous, the wan- 
dering, or the migrating abscess; and it is very commonly called the chronic 
abscess. The Germans call it Scnkungsabscess. Tuberculous abscess is the 
best designation, as this indicates the cause of the trouble. 

The term cold abscess is often used, because the cutaneous surface over the 
disease is not warmer to the touch than is the skin of the corresponding part of the 
opposite side of the body. The term lymphatic abscess was employed because 
it was once thought that such abscesses arose only from lymphatic structures. 
Scrofulous abscess was the name given it when scrofula was supposed to be a 
definite disease, the common phase of which was this form of abscess. The 
term chronic abscess is employed because the condition usually develops 
slowly, and does not present the evidences of acute inflammation; an acute 
pyogenic abscess developing, as a rule, rapidly, and presenting positive signs 
of inflammation. I agree with the late Professor Ashhurst that the term 
chronic, in this connection, is improper; as it tends to give a wrong idea. It 
refers merely to time; and we know that an acute pyogenic abscess that is 
deep-seated may be rather slow in developing, and that a tuberculous abscess 
that is superficial may develop with considerable rapidity. When used prop- 
erly, the term chronic abscess means that genuine pus exists, this pus having 
arisen from the pyogenic infection of the granulation-tissue of a lesion of syph- 
ilis, tuberculosis, or actinomycosis. In other words, a genuine chronic abscess 
is secondary pyogenic infection of an infective granuloma. The terms wan- 
dering, migrating, gravitating, and congestive have been used because the 
fluid products of a tuberculous inflammation are liable to wander a consider- 
able distance away from the primary focus of disease. For instance, a tuber- 
culous abscess that is discovered in the groin may have arisen from tuberculous 
caries of the vertebrae. This tendency to wander is not due to gravity, as one 
of the names of the condition would suggest; but the wandering always takes 
place in the line of least resistance. 

It will be seen from the foregoing that a true tuberculous abscess is not an 
abscess at all, because it does not contain genuine pus. It is a collection of the 
degenerated products of tuberculous inflammation; and a tuberculous abscess 
may be defined as a circumscribed cavity of new formation, containing the de- 
generated products of a tuberculous inflammation. These products may have 
been formed in that region or may have passed to that point from some adja- 
cent or distant focus of tuberculous disease. If a supposed tuberculous abscess 
is found to contain genuine pus, there must have been mixed infection with 
pyogenic bacteria; and such mixed infection either causes violent and danger- 
ous inflammation or leads to the formation of a true chronic abscess, in which 
there is no sign of acute inflammation. The tubercle bacillus is not pyogenic. 
It can produce inflammation, but not pus, and pus can be formed in a 
tuberculous focus only by secondary infection with pus bacteria. 



146 Suppuration and Abscess 

Situations of Tuberculous Abscesses. — These abscesses are particularly 
apt to form as the result of tuberculous disease of bones, joints, lymph-glands, 
and subcutaneous connective tissue; but the brain, any viscus, or any tissue in 
the body may present the condition. 

Age. — No age is exempt, but children are most prone to the trouble; and 
the period of greatest liability is before the age of twenty years. 

Contents. — The usual term for the contents is scrofulous, curdy, or caseous 
pus. As I said, it is not trus pus; but it resembles pus when viewed 
with the naked eye. Examination of this fluid by staining methods, by cul- 
tures, and by inoculations shows that it contains no pyogenic bacteria. It 
consists of liquefied and caseated tubercle; masses of coagulated fibrin; and 
bits of necrotic tissue. The tuberculous material is whitish, yellowish, or 
yellowish-green; thick; and without odor. Floating in this pus are portions 
of caseous matter, which, as the elder Gross said, resemble bits of soft boiled 
rice. Occasionally the tuberculous material, especially if it comes from disease 
of a lymph-gland or of a bone, is almost watery and nearly colorless, and con- 
tains curd-like masses, consisting of tuberculous granulations, coagulated fibrin, 
and necrotic tissue. It was previously stated that tuberculous pus is free 
from odor. This is not true of tuberculous pus of the ischiorectal fossa, which 
is highly putrid; but in an ischiorectal abscess, as a matter of fact, there is 
usually mixed infection with pyogenic organisms, as well as with the organisms 
of putrefaction. If tuberculous pus is permitted to stand, the curdy mass 
settles to the bottom, and a thin serous fluid remains above. 

Formation of Tuberculous Abscess. — During their growth, the tubercle 
bacilli in the tissues cause a chronic inflammation. The cells of the tissues, 
especially the fixed cells, proliferate and form granulation tissue. This 
granulation tissue consists of multitudes of cell clusters, and each cluster is 
called a primitive tubercle (page 213). Each individual tubercle enlarges; 
myriads of new ones form; and many of the old ones fuse. These new cells, 
however, do not become vascularized. In the earliest stage of their formation, 
there are blood-channels; but these become closed through endothelial prolifer- 
ation and through the pressure of cells external to them. The tuberculous area 
then becomes absolutely avascular. This avascular mass of cells is composed of 
what are known as epithelioid cells, and the cells obtain nourishment by imbibi- 
tion. The nourishment is very incomplete. As the nodule enlarges, the nour- 
ishment grows more and more insufficient. Finally, the adjacent blood-vessels 
that furnished the fluid for imbibition become occluded, and nourishment is 
no longer possible. The toxins of the tubercle bacilli, acting upon this area 
of greatly lowered nutritional activity, produce coagulation necrosis; and 
caseation follows this. The caseation begins at many points near the middle 
of the tuberculous nodule. Each area of caseation enlarges. Several of them 
fuse, and eventually many caseated areas coalesce. The tuberculous lesion may 
be spreading at the periphery at the same time that it is undergoing caseation 
at the center. The bacilli in the caseated material soon die for want of nourish- 
ment. When an area of caseated tubercle is liquefied by the addition of serum, 
what we call caseous or curdy pus is produced; and the lesion is then known as 
a tuberculous abscess. 

The Wall of the Abscess. — The wall of the abscess is formed by com- 
pressed or solidified tissues. In a very recent case the wall is soft and will readily 



Tuberculous Abscess 147 

collapse. In an old case it is dense or actually fibrous and will not collapse. 
This wall of compressed tissue is not, as used to be thought, a pyogenic mem- 
brane, which secretes the tuberculous material; but it actually surrounds the 
tuberculous material and hinders its diffusion. AsRoswell Park says, it is not 
a pyogenic membrane, but it is a prophylactic membrane. The inner surface of 
the wall of the compressed tissue is lined with tuberculous granulations, which 
at different points show different stages of the tuberculous lesion. This layer 
of tuberculous granulations is known as Volkmanrfs membrane. The fluid 
in the abscess may contain a few living bacteria, but often none can be found; 
and certainly the bacteria are not multiplying in this fluid, but they do multiply 
in Volkmann's membrane. When tuberculous matter has been long retained 
and thoroughly encapsulated the bacilli soon die for want of nourishment, 
and, because a culture from a supposed tuberculous area fails to show the 
bacilli of tuberculosis, we have not obtained conclusive evidence that the 
area is not tuberculous. We know this same fact to be true of the fluid of 
tuberculous empyema. 

From the abscess-wall there may be one, two, several, or many sinuses 
tracking out. These sinuses are lines with granulation tissue exactly like 
the Volkmann's membrane in the main abscess; and they may spread by a 
sort of crawling progression for long distances, perhaps passing through dense 
fascia, and at their terminations form secondary tuberculous abscesses. The 
wall of an abscess may contain expansions or loculi. If an abscess spreads 
to some distant place, the tuberculous infection, of course, goes with it; and it 
is the tuberculous infection that causes the spread. The wandering of a 
tuberculous abscess is in the line of least resistance and is not the result of 
gravity. Injury, breaking, or contusion of this granulation tissue, if unac- 
companied with the removal of all the tissue or the killing of all the germs 
it contains, may diffuse the pus and actually cause disseminated tuberculosis. 
We sometimes see such dissemination after spontaneous opening, non-aseptic 
operation, or forcible squeezing; and particularly after an imperfect opera- 
tion that removes only a part of the tuberculous area. 

Terminations of Tuberculous Abscess. — The abscess may slowly and 
gradually enlarge, and finally open of itself, either on the skin or on the mu- 
cous surface, or into some viscus or joint. It may become encapsulated by 
fibrous tissue, there being absorption of the fluid and shrinking of the entire focus, 
the caseous part perhaps remaining or becoming calcified. The tuberculous 
abscess may actually be replaced by fibrous tissue, and this constitutes a per- 
manent cure. When the tuberculous area is merely encapsuled by fibrous 
tissue, some living bacilli may remain latent in the wall; and long afterwards, 
as the result of injury or of some other damage, an abscess may reform at the 
old site of disease. Sir James Paget calls this condition residual abscess, 
As a rule, the abscess, as it shrinks, tends toward cure. The bacilli usually 
die for want of material to nourish them; but occasionally they remain latent 
for a long period of time. When they do die, the tuberculous granulation 
tissue may become healthy tissue, be vascularized through the entrance of 
blood-vessels, and be converted into scar-tissue. Tuberculous abscess may 
also be cured by a surgical operation. 

Secondary Infection of a Tuberculous Area with the Bacilli of 
Suppuration. — This is liable to occur when the abscess undergoes sponta- 



148 Suppuration and Abscess 

neous evacuation, and may occur when it has been opened by the surgeon. It 
occasionally occurs when the abscess has neither undergone spontaneous evacu- 
ation nor has been opened by the surgeon, having been infected apparently 
as a point of least resistance. When such infection does occur, there is, in all 
probability, some area of ordinary suppuration elsewhere in the person's body; 
and the bacteria of suppuration have entered the body fluids. Pyogenic in- 
fection is apt to produce violent inflammation and profuse suppuration — a 
condition that is extremely dangerous, because septicemia is very liable to 
develop. In some very rare cases suppuration destroys the tuberculous area 
and cures the tuberculous disease. More commonly, however, it produces 
illness; and in large abscesses it may cause- death. Because of this liability 
to secondary infection surgeons were long opposed to operating on tuber- 
culous abscess unless it was evidently going to evacuate itself. In some 
cases, secondary infection produces a true chronic abscess (page 145). 
Infection with streptococci is much more dangerous than is infection with 
staphylococci. Acute inflammation with dangerous constitutional symptoms 
is particularly apt to arise: if the walls of the abscess contain very little 
tuberculous tissue, if they have been bruised or damaged with powerful chemi- 
cals ; if there is poor drainage (and there is certain to be poor drainage if loculi 
exist, or when the incision is small and blocked with plugs of fibrin or necrotic 
tissue), if a partial or imperfect operation has been performed, if a number of 
virulent bacteria have been introduced, or if the vital resistance is at a low ebb. 

Secondary Infection with the Bacteria of Putrefaction. — This com- 
plication is extremely grave and may produce death. It is commonly as- 
sociated with pyogenic infection. The wound-fluid becomes intensely putrid, 
violent acute inflammation arises, and the absorption of materials from the 
wound induces the systemic condition known as sapremia or putrid intoxi- 
cation. 

Signs and Symptoms of Tuberculous Abscess. — A purely tuberculous 
abscess presents no evidence of inflammation, except swelling; and, owing 
to the absence of heat, it has received its name of cold abscess. The cutane- 
ous surface looks and feels normal or is paler than normally, until the struc- 
tures just beneath the skin or the skin itself become involved. When this 
happens, livid discoloration appears; but the lividity presents a very different 
appearance from the dusky discoloration of an acute abscess. Neither is the 
skin edematous or glossy as it is in acute abscess. 

There is rarely tenderness in the region of the abscess, and still more rarely 
spontaneous pain. Pain and tenderness, although frequently absent in the 
area of a tuberculous abscess, may be complained of at the primary focus of 
disease. Tenderness is especially likely to be noted at the primary focus; 
and in cases of joint-tuberculosis and of bone-tuberculosis, it is nearly always 
present. There may or may not be pain at the primary focus, but there 
is frequently referred pain. For instance, in tuberculous disease of the hip- 
joint the pain may be referred to the inner side of the knee; and severe belly- 
ache is frequently observed in Pott's disease of the spine. At the point to 
which pain is referred, however, there is no tenderness. For instance, in the 
belly-ache, particularly of Pott's disease of the spine, the belly is not tender 
although the spine is. In sacroiliac tuberculosis the disease is often referred to 
the distribution of the sciatic nerve; but the nerve is seldom tender on pressure. 



Tuberculous Abscess 149 

In a psoas abscess we find that pain in the spine can be induced by pressing 
on the spinous process of the diseased vertebra, by concussion to the heels or 
the head when the spine is held stiff, and especially by flexion of the spine; but 
the spinal pain is lessened or completely abolished by extension, fixation, and 
rest. The primary focus of disease, if spinal or articular, produces rigidity 
in the adjacent muscles; and rigidity obtains rest by inhibiting movement, 
but it also impairs the function of the part. In an intra-abdominal tubercu- 
lous abscess, there is rigidity of the abdominal muscles. 

In a tuberculous abscess fluctuation is usually obtained readily because 
the fluid is not surrounded by a thick mass of granulation tissue and also be- 
cause a considerable amount of fluid is usually present. A notable character- 
istic of a tuberculous abscess is the tendency to wander, and it may appear 
with suddenness at some distant point. Abscesses of the spine wander long 
distances, but the wandering is not the effect of gravity and is due to the 
disposition of the tuberculous matter to travel in the line of least resistance. 
The temperature of the body may be entirely normal if the infection is purely 
tuberculous. As a rule, however, there is a slight evening elevation; and the 
patient is weak and pale, grows tired readily, sleeps poorly, and has a wretched 
appetite and impaired digestion. The blood examination sometimes, but not 
often, shows a notable diminution in the number of red blood-cells; but the 
hemoglobin is usually lowered to 60 or 70 per cent. There is no leukocytosis. 
In multiple tuberculous foci, and particularly in tuberculosis in children, there 
is a marked decrease in the red blood-cells. If secondary infection occurs, 
there is a rapid and progressive diminution in the number of these cells and 
usually leukocytosis. 

A tuberculous abscess underneath the deeper fascia may break through 
the fascia by way of a small opening, and a large secondary abscess may arise 
in the subcutaneous tissue. The entire abscess is thus shaped like an hour- 
glass, the opening through the fascia being the narrowest point. Such an 
abscess is called a shirt-stud abscess. A tuberculous abscess is liable to form 
one, several, or many sinuses; and the end of each sinus may expand into a 
secondary abscess. The surgeon must always make a careful examination 
to try to determine whether the abscess is the primary disease-focus or whether 
the tuberculous matter has wandered from a distant point. He must also make 
a thorough examination to see whether anywhere in the body there are other 
regions of disease. He will often find such areas; for instance, in the lungs. 
In many cases, however, there is no clinical evidence that other areas exist. 

The tuberculous abscess usually requires weeks or months to reach the 
overlying skin or mucous membrane and undergo spontaneous evacuation. 
That spontaneous evacuation is imminent is shown by livid discoloration and 
thinning of the skin. Finally, at the very thinnest point, a little tit is elevated. 
This condition is known as pointing and a rupture occurs at this point, tubercu- 
lous pus running out. Spontaneous evacuation is a peril, because it is liable 
to be followed by secondary pyogenic or putrefactive infection. After spon- 
taneous evacuation has occurred, a true chronic abscess may form; but there 
may instead be violent acute inflammation, manifested by pain, heat, and dusky 
discoloration. If acute inflammation does arise, there develops a fever, which 
presents evening exacerbations and morning remissions, and is accompanied 
by an exhausting sweat during the night or early morning. Fatal septicemia 
or sapremia may follow spontaneous evacuation. 



150 Suppuration and Abscess 

Results of a Tuberculous Abscess. — It may undergo spontaneous 
cure, and the cure may be lasting; but long after an apparent cure, a new 
abscess may form (the residual abscess of Sir James Paget). A tuberculous 
abscess may remain stationary for a very long time, and then perhaps diminish 
in size and be cured, or extend in size and rupture. After spontaneous rupture, 
suppuration may cure the tuberculous area by annihilating the tuberculous 
tissue; but, as a rule, after spontaneous rupture there is either an acute septic 
process or a chronic suppuration, constituting a genuine chronic abscess. 

The pyogenic infection of a tuberculous area, if it induces long-lasting 
suppuration, may lead to the development of albuminoid, amyloid, waxy or 
lardaceous disease in the middle and inner coats of blood-vessels, in connec- 
tive tissue, lymphatic glands, the membrana propria of mucous membranes, 
the heart, the liver, the spleen, and the kidneys. The victim of albuminoid dis- 
ease is pale, greatly exhausted and emaciated, and very anemic; suffers with 
diarrhea and usually has capillary hemorrhages beneath the skin and 
mucous membranes. The albuminoid material can be detected chemically in 
the urine, if the kidneys are involved. Albuminoid degeneration is incura- 
ble, and is usually fatal; but if the patient is subjected to proper treatment 
soon after it begins it may be arrested and not progress. The amyloid material 
is deposited between the cells and not in them. The disease is apt to arise 
in chronic tuberculosis with secondary pyogenic infection, especially in bone 
tuberculosis, but it may arise in syphilis, chronic suppuration in non-tubercu- 
lous subjects, and chronic dysentery. The albuminoid substance resembles 
fibrin and there are many theories as to its source. One theory is that the 
condition is due to the flow of pus removing potash salts from the blood, and 
thus leaving a dealkalinized blood-serum. 

Diagnosis. — The fluctuation, the absence of evidences of acute inflamma- 
tion, the tendency to wander, and, in some cases, the sudden appearance, mark 
the diagnosis. The surgeon always examines with care to see whether there is 
some distant tuberculous focus from which the abscess may have wandered, or 
whether the abscess itself is at the primary seat of disease. The advancing 
impairment of the general health, the lessened amount of hemoglobin, the 
normal or almost normal temperature, and the absence of leukocytosis are 
points in the- diagnosis of the condition. In a doubtful case the aseptic use of 
the tubular exploring needle is important, the fluid that emerges being studied 
with the microscope after staining, by cultures, and perhaps by inoculating 
it into guinea-pigs. The fluid that is withdrawn may contain no bacteria 
that can be demonstrated; but if it is sterile and there are no pyogenic organ- 
isms, one should strongly suspect tuberculosis. 

Prognosis. — Advanced albuminoid degeneration gives a hopeless prog- 
nosis and any extent of albuminoid degeneration is unfavorable. Secondary 
pyogenic infection, as already stated, may produce death or a lingering 
suppuration. The prognosis is worse in very young children than in adults; 
and in any case it is unfavorable if the exhaustion deepens, if the anemia is 
marked, if there are tuberculous lesions in distant parts or in important organs 
or structures, if the patient is unable to take and digest food, and if the regions 
of tuberculosis cannot be extirpated or sterilized. Under other circumstances, 
the prognosis is favorable. 

Tuberculous Abscesses in Various Regions. — Tuberculous abscess 



Tuberculous Abscess 151 

of the head of a bone (see Brodie's abscess, page 434) arises in the can- 
cellous structure of a long bone, most often in the head of the tibia, and is 
frequently noted as having been preceded by a trivial traumatism. The focus 
of tuberculosis seldom induces severe symptoms unless secondary pyogenic in- 
fection occurs (page 214). A tuberculous nodule forms as a result of tubercu- 
lous osteomyelitis. The bone about the nodule is hyperemic, the bony tra- 
becule are thickened, and the cancellous spaces "are devoid of fat cells, and 
they contain a swollen semi-fibrous material" (Warren's "Surg. Pathol. "). The 
center of the nodule becomes cheesy, the bone trabecular are absorbed and the 
bone becomes cheesy and broken up, the cheesy mass containing bone frag- 
ments. Finally the area becomes filled with tuberculous pus, the cavity which 
contains it being lined with tuberculous granulations. Distinct sequestra may 
form and the bone about the diseased focus undergoes sclerosis. In Brodie's 
abscess pain is continued but is not usually very severe, is of a boring character, 
and is worse when the patient is in bed. Attacks of synovitis arise from time to 
time in the adjacent joint. The bacteria of tuberculosis obtain access to the 
bone by means of the blood, and find in the bone a point of least resistance. 
There is no such thing as an acute abscess of bone. A pyogenic inflammation, 
of such severity that it would cause an acute abscess in soft parts, in bone 
causes acute necrosis. 

Retropharyngeal or postpharyngeal abscess is often tuberculous. Such 
an abscess is usually due to caries of the cervical vertebra?, but can arise in the 
connective tissue of the parts or as a tuberculous adenitis. An abrasion of 
the mucous membrane may admit the bacilli to the connective tissue or the 
glands. A swelling projects from the posterior pharyngeal wall, and there is 
great interference with respiration and deglutition. Caseous matter from 
caries of the cervical vertebra? may reach the posterior mediastinum by following 
the esophagus, or may appear in front of or behind the sternomastoid muscle in 
the neck (Edmund Owen). A tuberculous abscess in this region is apt to un- 
dergo pyogenic infection, in which case the patient develops fever, sweats, pain, 
and prostration. 

Dorsal Abscess. — The tuberculous matter in dorsal abscess arises from 
dorsal caries, flows into the posterior mediastinum, and reaches the surface 
by passing between the transverse processes. The tuberculous matter from 
dorsal caries may run forward between the intercostal muscles or between 
these muscles and the pleura, pointing in an intercostal space, at the side of the 
sternum, or by the rectus muscle. It may burst into the gullet, windpipe, 
bronchus, pleural sac, or pericardium. It may descend to the diaphragm 
and travel under the inner arcuate ligament to form a psoas abscess, or under 
the outer arcuate ligament to form a lumbar abscess. A psoas abscess points 
external to the femoral vessels, a characteristic which distinguishes it at once 
from a femoral hernia. 

Iliac abscess arises from lumbar caries, the swelling lying in the iliac fossa 
and pointing above Poupart's ligament. 

Psoas abscess is usually due to lumbar caries, but may arise from dorsal 
caries. The fluid usually points in Scarpa's triangle external to the femoral 
vessels, but may descend much lower (Fig. 72). A psoas or iliac abscess, by 
following the lumbosacral cord and great sciatic nerve, forms a gluteal abscess. 
These abscesses may open into the bowel, bladder, ureter, or peritoneal cavity. 



152 



Suppuration and Abscess 



Lumbar Abscess. — In a lumbar abscess the fluid produced by dorsal 
caries descends beneath the outer arcuate ligament, or the fluid from lum- 
bar caries which collected anterior to or in the quadratus lumborum muscle 
passes between the last rib and iliac crest in the triangle of Petit, the small 
space bounded by the crest of the ilium, the posterior edge of the external 
oblique muscle, and the anterior edge of the latissimus dorsi muscle.* 

Tuberculous abscess of the neck results from tuberculosis of the cervical 
glands. It is not often that such an abscess attains any considerable 
size. It tends strongly to spontaneous rupture, and, if this is permitted to 
occur, a livid, corrugated scar results. 

Tuberculous abscesses of joints (see Chapter XIX). 
Tuberculous Abscess of Rib. — It is not uncommon to find a tubercu- 
lous abscess of moderate size about a tuberculous rib. The pleura may 
become involved secondarily. 

Tuberculous mediastinal abscess may result from the downward 

passage of a cervical abscess; from tuber- 
culosis of the sternum, ribs, vertebrae or 
pleura, or from tuberculous mediastinal 
glands. 

Chronic abscess of the breast is a 
caseated and liquefied area of tuberculosis 
of the breast. A lump is detected, which 
slowly enlarges and finally ruptures, sinuses 
being formed. The axillary glands are apt 
to be implicated. The patient may belong 
to a tuberculous stock, as a rule gives a 
history of previous Tuberculous troubles of 
various sorts, and has usually borne 
children. Chronic abscess of the breast 
causes little or no pain. 

Treatment of Tuberculous Abscess. 
— For many years the majority of surgeons 
would not operate upon a tuberculous ab- 
scess unless it was on the point of ruptur- 
ing. With the advent of antiseptic sur- 
gery, it was assumed that aseptic in- 
cision and drainage would be the proper treatment for these cases; 
but the results, except in small superficial tuberculous abscesses, have been ex- 
tremely disappointing. If a large abscess is so treated, pyogenic infection will, 
in all probability, sooner or later occur, with all its possibilities of disaster. 
Incision and drainage is, therefore, restricted to small and superficial abscesses. 
Treatment of Small Superficial Tuberculous Abscesses. — The surgeon 
must remember that after one has opened an apparently superficial abscess 
it is his duty to make an examination to see that there is no channel connecting 
the abscess with a deep or a distant focus. If he finds such a channel, he may be 
disposed to follow one of the plans of treatment outlined on pages 153 and 154. 
It is also his duty to see whether there are sinuses tracking off from the abscess; 

*For a lucid description of these abscesses see Owen's "Manual of Anatomy," from 
which much of the above is condensed. 




Fig. 72. — Psoas abscess (Albert). 



Tuberculous Abscess 



153 



and if these exist, he must slit them up. If there are loculi in the wall of the 
abscess, he must stretch their mouths. He must be particularly careful to see 
that he is not dealing with a shirt-stud abscess, in which there is a little opening 
through the deep fascia connecting the abscess above with the abscess below. 
In a shirt-stud abscess the deep fascia must be freely incised. After the abscess 
has emptied itself, its walls must be thoroughly scraped with a curet, and the 
cavity must be drained with a tube or, preferably, packed with iodoform 
gauze. If the skin above a superficial abscess is diseased and discolored, and 
the abscess is on the eve of spontaneous rupture or has ruptured, the dis- 
colored skin must be cut away with scissors. If the discolored skin is allowed 
to remain, a livid and jagged scar will inevitably result. If it is cut away, 
a healthy scar, not very deforming, will result. 

Treatment of Tuberculous Abscesses of Considerable Size. — Method 
1. Aspiration, Irrigation, and the Introduction oj Iodoform. — The operation 
is carried out with the most scrupu- 
lous aseptic care. The trocar is 
passed through the sound skin; is 
carried beneath the skin for an inch, 
as Senn suggests; and is then made 
to enter into the cavity of the abscess. 
The stylet is pulled out, and the flow 
of fluid is aided with very delicate 
pressure. Occasionally the tube will 
become blocked by necrosed tissue or 
plugs of fibrin. It is opened up again 
by pushing in a wire or forcing in a 
stream of sterile fluid. When tuber- 
culous matter ceased to run out of the 
trocar, a very warm solution of bor- 
acic acid is thrown in in order to wash 
the abscess- walls. This can be in- 
serted with a fountain syringe or with 
the special apparatus of Senn (Fig. 
73). Enough of it is allowed to enter 
to over-distend the abscess-cavity, 
The fluid is then allowed to pass out; fresh fluid is passed in; and this 
procedure is repeated, perhaps again and again, until entirely clear fluid flows 
out. When this takes place, an emulsion of iodoform is thrown in by Senn's 
syringe. A ten per cent, emulsion in glycerin is as satisfactory as the more 
elaborate formulas. Verneuil used to employ iodoform and ether; but 
this is painful, is more liable to cause iodoform poisoning, and sometimes 
induces gaseous distention and ruptures the wall of the abscess. In order to 
prevent the danger of iodoform poisoning the surgeon should not introduce at 
one time more than eight drams of the emulsion, if dealing with an adult; 
or more than four drams, if dealing with a child. After the emulsion has been 
inserted into the abscess-cavity, the wound in the skin is sealed with a bit of 
gauze and iodoform collodion. Gauze is fluffed up and laid on the skin 
above the abscess, and the walls of the cavity are then forced toward each 
other by applying a roller bandage. The part is put at complete rest, and it is 




Fig. 73. — Semi's injection syringe. 



as Mr. Callender long ago advised. 



154 Suppuration and Abscess 

usually necessary to put the patient in bed. Sometimes, although very seldom, 
one injection will produce a cure; but usually, after one or two weeks, it will 
be observed that the cavity has to some extent filled again. A second opera- 
tion is then performed; and, if improvement is really taking place, it will be 
found that the fluid is not nearly so thin as it was at the first operation. It is 
needless to persist in this method after six or seven attempts have failed to cure. 
If the abscess has thick and uncollapsed walls, it is not fitted for treatment by 
aspiration and injection. 

Method 2. Incision, Cleansing, and Suture. — If, owing to the considerable 
size or the rather rigid walls of the abscess, one believes that the- aspiration 
method would be useless; or if the aspiration method has been tried and has 
failed, one may adopt the following plan. It should not, however, be em- 
ployed, if the walls are very thick and rigid. An incision is made at the most 
dependent part of the abscess. The walls are scraped carefully with Barker's 
sharp-edged irrigating curet (Fig. 74), and are rubbed smooth with bits of 



I 












- — — ' 


^^— — —win 



















Fig. 74.— Barker's sharp-edged irrigating euret (Keen's Surgery). 

gauze. The part is freely irrigated with hot boracic acid solution, and pressure 
is applied to arrest bleeding. Iodoform emulsion is introduced; the skin is 
sutured; dressings, compresses, and bandages are applied; and complete rest 
is secured. This operation may cure an 'abscess; or it may be necessary to 
repeat the procedure two or three weeks, or many weeks, afterward. 

Method 3. Incision and Removal 0} the Primary Focus of Tuberculosis. — If 
one has not used the iodoform treatment, or if it has failed and if one finds that 
the primary seat of disease may be attacked and removed, an operation should 
be undertaken to get rid of Volkmann's membrane in the last-formed abscess 
and also to remove the primary tuberculous focus. An incision is made, when 
possible, that will lay open not only the last-formed abscess, but the primary 
lesion. Tuberculous tissue is thoroughly removed with Barker's spoon and 
by rubbing with gauze, or, perhaps, by scissors and forceps. Any focus of 
bone disease is curetted and touched with pure carbolic acid, and loose frag- 
ments of bone are removed. The part is irrigated with a hot solution of 
boracic acid; bleeding is arrested by pressure; and the wound is nearly, but 
not quite, closed, drainage being inserted at the most appropriate spot. Dress- 
ings, compresses, and bandages are then applied. In this operation, the en- 
tire tuberculous area has been removed, and the raw surfaces have been forced 
into contact; and there is no more danger of secondary pyogenic infection 
than there is in any ordinary wound. 

General Treatment. — It is never to be lost sight of that in every case of 
tuberculous abscess the general treatment of tuberculosis must be rigorously 
pursued (see page 225). In the treatment of a cold abscess give nutritious 



Tuberculous Abscess 155 

food, cod-liver oil, quinin, iron, and the mineral acids. Removal to the sea- 
side is often indicated, life in the open air is imperative, and mechanical appli- 
ances may be needed for diseases of the bones and joints. 

Chronic Abscess of Bone. — Make an incision to bare the bone. Open 
the abscess with the trephine, the gouge, or the chisel; curet interior of the 
wall of the cavity with a sharp spoon and rub it with bits of gauze; cut away 
the edges of the bone with rongeur forceps; irrigate the cavity with hot normal 
salt solution, dry its walls with gauze, and paint the cavity with pure car- 
bolic acid; pack with iodoform gauze and apply antiseptic dressings. It is 
better not to employ an Esmarch apparatus. Bleeding will not be severe, 
and when no apparatus is used to prevent bleeding one can be sure that all 
the diseased bone has been removed, because sound bone bleeds and dead 
bone does not. 

Cold Abscess of Lymphatic Glands. — In non-exposed portions of the 
body the capsule of the gland should be incised and dissected or scraped away 
and the cavity swabbed out with pure carbolic acid and packed with iodoform 
gauze. If the abscess is allowed to burst, it will cause an ugly scar; therefore 
in exposed portions of the body, as the neck, special effort should be made to 
prevent a scar by incising early before the skin is involved. When only a 
little caseated matter exists and the skin is not discolored, prepare the parts 
antiseptically, incise, rub the interior with gauze, inject iodoform emulsion, 
and suture the wound. It used to be a custom in such cases to carry a silk 
thread by means of a needle through the skin, through the gland, and out at 
its lowest point, the part being then dressed with gauze. In three days the 
thread was removed and a firm compress was applied. The plan is not satis- 
factory and incision is to be preferred. When the gland is almost entirely 
broken down and the skin above it is becoming purple and thin, insert a 
hypodermatic needle through sound skin into the abscess, draw off the fluid 
tuberculous matter, and inject iodoform emulsion. This procedure is to be 
repeated when the fluid again accumulates. By this means we can some- 
times effect a cure in a week or so. When an abscess breaks or is on the 
point of breaking, cut away all purple skin, curet the abscess-walls (the 
abscess having become a tuberculous ulcer), remove the remains of gland and 
capsule, swab the cavity with pure carbolic acid, and dress with iodoform and 
antiseptic gauze. 

Tuberculous glands ought to be extirpated before they caseate and form 
an absce--. 

Tuberculous Abscess of a Rib. — This lesion recjuires incision of the 
soft parts and resection of the diseased bone. The tuberculous area is 
thoroughly curetted, rubbed with pure carbolic acid, and packed with iodo- 
form gauze. 

Tuberculous Mediastinal Abscess. — In tuberculous abscess of the me- 
diastinum aspiration and injection of iodoform may prove efficient. In some 
cases it will be necessary to open and drain. 

Cold Abscess of the Mammary Gland. — Many operators simply incise, 
curet, pack with iodoform gauze, and dress antiseptically. It is wiser to 
remove the entire gland, and to clear out the axilla, as in an operation for 
cancer, in order to prevent both recurrence and dissemination. 

Large Cold Abscesses. — In view of the facts that these abscesses may 



156 Suppuration and Abscess 

cause no trouble for years and that an operation may be fatal, some eminent 
surgeons are opposed to an operation unless the abscess is moving toward 
inevitable rupture or is disturbing the functions of organs by pressure. Most 
practitioners believe, however, and I agree with them, that this mass of 
tuberculous matter is a source of danger through being a depot of infective 
organisms which may overwhelm the system, and that death will seldom 
result from an operation performed by one who employs with intelligence 
strict antisepsis. In no other cases is attention to every detail more impor- 
tant, as a mixed infection may easily take place, and will probablv mean 
death. As W. Watson Cheyne points out, over seventy per cent, of cases 
of spinal abscess treated by aseptic methods recover completely and without 
any real illness after such an operation. The recoveries from the old let- 
alone method will be infinitely less than this, and cases cured by operation 
usually remain well. The surgeon must always remember that the wall of 
the abscess and not the fluid in the cavity is the real seat of disease, and 
this wall must be actually removed or completely sterilized if operation is 
to be safe. To simply open, drain, and leave the wall to Nature to get rid 
of if she can is fraught with the gravest peril. 

Psoas Abscess. — Some of these cases can be treated by aspiration and 
injection (page 153), others by incision and subsequent suture (page 154), 
others by the radical operation set forth on page 154. 

Treves's operation for psoas abscess is described on page 618. 

An operation occasionally performed for psoas abscess consists in an 
incision in the groin, an incision in the back, removal of carious vertebrae, 
thorough cleansing of the abscess-wall, and through-and-through tubular 
drainage. It has been found, however, that this operation is uncertain and 
dangerous. It is not advisable to remove carious vertebrae, and through-and- 
through tubular drainage is rarely used unless mixed infection already exists. 
When a large abscess breaks spontaneously, it should be widelv opened at 
once, scraped and irrigated, rubbed with gauze, swabbed with pure carbolic 
acid, washed out with alcohol, and packed with iodoform gauze. If secondary 
pyogenic infection of a large tuberculous abscess does occur, the patient will 
develop septic fever and will probably die (q. v.). 

Dorsal abscess and lumbar abscess are treated after the same plan as 
psoas abscess. One incision only is usually necessary unless the fluid has 
traveled to a distant point. 

A postpharyngeal abscess must not be opened through the mouth. To 
open it in this manner puts the patient in danger of suffocation by fluid running 
into the larynx during or after the operation. Further, mixed infection of the 
abscess-area will be certain to ensue. Septic pneumonia will be apt to arise 
from inhaled infected particles, and profound gastro-intestinal disturbance 
will be liable to develop because of the inevitable swallowing of purulent, 
putrid, and tuberculous masses. Incise the neck and open into the abscess 
by Hilton's method, going through the sternocleidomastoid muscle or behind 
it. Rub the wall of the abscess with bits of gauze, remove any loose bone, 
irrigate with hot normal salt solution, inject iodoform emulsion, insert a tube 
or pack with iodoform gauze. 



Classification of Ulcers 157 



VII. ULCERATION AND FISTULA. 

Ax ulcer is a loss of substance due to molecular death of a superficial 
structure. The molecular death is brought about by bacteria. Ordinary 
ulcers are caused by pus organisms. The action of the pus organisms is the 
same as in an abscess. A broken abscess becomes an ulcer, and an ulcer is 
in structure a half-section of an abscess. The floor of an ulcer consists of 
granulation tissue and corresponds with the abscess-wall. An abscess arises 
from molecular death within the tissues; an ulcer, from molecular death of 
a free surface. An ulcer may increase in size by molecular death of adja- 
cent structures or by sloughing, that is to say, by death of visible masses of 
tissue. A wound healing by granulation is often wrongly called an ulcer. 
An ulcer must not be confounded with an excoriation. In an ulcer the corium 
is always, and the subcutaneous tissue is generally, destroyed, and a scar is 
left after healing. In an excoriation the mucous layer of epithelium is ex- 
posed, or this is destroyed and the corium is exposed. In an excoriation the 
corium is never destroyed, and no scar remains after healing. An ulcer heals 
by granulation (page 113). Embryonic tissue by vascularization becomes 
granulation tissue, granulation tissue is converted into fibrous tissue, the fibrous 
tissue contracts, and by pulling the edges of the ulcer toward each other lessens 
the size of the cavity. When the granulations reach the level of the skin the 
epithelium at the edges of the ulcer proliferates and the sore is soon covered 
over with new epithelium. 

Necrosis of a superficial part may arise from — (1) Inflammation. The 
pressure of the exudate can cut off the circulation, or bacteria may directly 
destroy tissue. Suppuration occurs. (2) The action of pus bacteria, causing 
primary cell-necrosis. (3) Bacteria of putrefaction and organisms of suppura- 
tion acting*upon a wound. (4) Traumatism or irritants, producing at once 
stasis, which is added to by secondary inflammation, the exudate undergoing 
purulent liquefaction. (5) Prolonged pressure. (6) Deficient blood-supply. 
(7) Faulty venous return. (8) Degeneration of a neoplastic infiltration 
(gummatous, malignant, or tuberculous). (9) Trophic disturbance. (10) 
Nutritional disturbances (as scurvy). Most ulcers are due to pus organisms, 
and even areas of necrosis that arise from something else (as gummatous 
degeneration) are likely to suppurate. 

Classification. — Ulcers are classified into groups according to the con- 
dition of the ulcer and the associated constitutional state. In the first group 
we find the varicose, hemorrhagic, acute, chronic, irritable, neuralgic, etc. 
In the second group are placed the tuberculous, syphilitic, senile, scorbutic, 
etc. All ulcers, whatever their origin, are either acute or chronic, and such 
conditions as great pain, hemorrhage, edema, exuberant granulations, phage- 
dena, sloughing, eczema, gout, syphilis, scurvy, etc., are to be looked upon 
as complications. The leg is so common a site of ulcers as to warrant a special 
description of ulcers of this part. In describing an ulcer state the patient's 
previous history; the supposed cause; the situation; the outline; the dura- 
tion; and the mode of onset of the ulcer. State if the ulcer is single or if 
multiple sores exist, and if there is or is not pain. Whether or not any healing 
has ever occurred, and the patient's constitutional condition. Set forth the 



158 Ulceration and Fistula 

complications; the state of anatomically related glands; the condition of the 
edge, the floor, and the parts about the ulcer, and the nature and quantity of 
the discharge. 

Acute or inflamed ulcer of the leg may follow an acute inflammation 
and may be acute from the start, or may be first chronic and then become acute. 
It is especially common in drunkards, and among those of dilapidated con- 
stitutions. It is characterized by rapid progress and intense inflammation. 
There is rarely more than one ulcer. In outline these ulcers are usually oval, 
but may be irregular. The floor of an acute ulcer contains no granulations, 
but is composed of the raw and inflamed tissues, or is covered with a mass of 
gray aplastic lymph, or it may have upon it large greenish sloughs. The 
edges are thin and undermined. The discharge is very profuse and ichorous, 
excoriating the surrounding parts. The adjacent cutaneous surface is in- 
flamed and edematous, and there is much burning pain. In some cases the 
glands in the groin enlarge. Constitutionally, there is gastro-intestinal de- 
rangement, but rarely fever. When the ulcer spreads with great rapidity 
and becomes deeper as well as larger in surface area, it is called " phagedenic." 
The formation of sloughs indicates that tissue death is going on so rapidly 
that the dead portions have not time to break down and be cast off. Limited 
stasis produces molecular death; more extensive stasis, a slough. If a chronic 
ulcer becomes acute, the granulations are destroyed. 

Treatment. — In treating an acute ulcer of the leg, give a dose of blue 
mass or calomel, followed in eight or ten hours by a saline (5ij each of Rochelle 
and Epsom salts), and order light diet. Deny stimulants except in a case of 
diphtheritic ulcer. Administer opium if pain is severe. Spray the ulcer 
with hydrogen peroxid, use the scissors and forceps to get rid of sloughs, and 
after sloughs are removed wash the ulcer with corrosive sublimate solution 
(1 : 1000), or paint it with pure carbolic acid. Paint the skin adjacent to the 
ulcer with equal parts of tincture of iodin and alcohol. Dress with hot anti- 
septic fomentations. Apply a bandage from the toes to well above the ulcer. 
Insist on the patient remaining in bed with the leg slightly elevated. Change 
the dressings before they become cool and always as soon as they are satu- 
rated with discharge. Every day paint the parts about the ulcer with equal 
parts of iodin and alcohol. 

Many cases do very well after antiseptization, and dusting the ulcer with 
iodoform, lead-water and laudanum being applied to the inflamed parts around 
the ulcer; but in a bad case hot antiseptic fomentations, compression, and 
elevation are more useful until sloughs separate. If the discharge is offen- 
sive, apply acetanilid, aristol, or iodoform, or use gr. iij of chloral to sj of 
water, before applying hot fomentations or ordinary antiseptic dressings. A 
25 per cent, ointment of ichthyol is very useful when applied to parts around 
the ulcer. If sloughs continue to form, touch the sloughing area with a 1 : 8 
solution of acid nitrate of mercury or with a solution of pure carbolic acid, 
and reapply antiseptic fomentations. If an ulcer continues to spread, clean 
with peroxid of hydrogen, dry with absorbent cotton, touch with nitrate of 
mercury solution (1: 8), and apply an antiseptic fomentation. Repeat appli- 
cation of nitrate of mercury every day until the ulcer ceases to extend and granu- 
lations begin to form. When granulations begin to form moist hot dressings 
are no longer necessary, and dry aseptic or antiseptic dressings can be used. 



Chronic Ulcer of the Leg 159 

If an ulcer is covered with a great mass of aplastic lymph, touch daily with a 
solution of silver nitrate (gr. xl to § j) or with acid nitrate of mercury (1 : 15), 
and dress with iodoform and antiseptic fomentations. Give internally tonics, 
stimulants, and nutritious liquid food. In any case, when granulations form, 
dress antiseptically with dry dressings, or employ a non-irritant ointment, such 
as cosmolin. If granulations form slowly touch them every day with a solution 
of silver nitrate (gr. x to gj) and dress antiseptically, or apply a stimulating 
ointment (resin cerate or 5j of ung. hydrarg. nitratis to 5vij of ung. petrolii, 
or an ointment of copper sulphate, gr. iij to gj), or dress with gauze soaked 
in a solution of 3 drops of nitric acid to gj of gum Arabic. 

Chronic ulcer of the leg is characterized by low action and slow prog- 
ress. It may be chronic from the start, or it may result from acute ulcer. 
Usually it is found as a solitary ulcer two inches above the internal mal- 
leolus. Syphilitic ulcers often occur in a group, are usually crescentic, and 
are frequent upon the front of knee. A tuberculous ulcer may have no granu- 
lations, but is usually covered with pale edematous granulations, which signify 
the existence of a tendency to venous stasis. The edges of the tuberculous 
ulcer are undermined and irregular, the parts about it are livid and tender, 
and the discharge is thin and scanty (page 230). An ordinary chronic ulcer 
is circular or oval, and is surrounded by congested, discolored, and indurated 
skin, this induration being due to fibrous tissue, and there is often eczema or a 
brown pigmentation of the neighboring skin. The floor of the ulcer is uneven, 
and usually is covered with granulations, each of which is red and the size of 
a pin-point, but which may be exuberant or edematous. If granulations are 
absent, the ulcer has the appearance of a piece of liver, or is smooth and 
glazed. The edges are thick, turned out, and not sensitive to the touch. 
Occasionally, but rarely, they are thin and undermined. Some ulcers are 
indurated and adherent; this adhesion to the deeper structures prevents 
healing by antagonizing contraction. An ulcer may fail to heal because of 
severe infection; because of want of rest; because of absence of granulations 
resulting from deficient blood-supply; because of edematous granulations; be- 
cause of exuberant granulations; because of adhesion to deep structures, or 
because of some constitutional disease. 

Treatment. — In treating a chronic ulcer, give a saline cathartic every 
day or so. Treat any existing diathesis. Insist on rest and, if possible, 
elevation. Asepticize the ulcer. Draw blood by shallow scarifications of the 
bottom and edges of the ulcer and the 
skin about it. If the ulcer is adherent to 
deeper structures, make incisions like 
those shown in Fig. 75, each cut going 
through the deep fascia. These incisions, 
besides permitting contraction, allow gran- 
ulation to sprout in the cuts and absorb 
exudate. Nussbaum advocated encir- Fig . 75 ._i nc isions for adherent ulcer, 

cling the ulcer with an incision about 

one-half or two-thirds of an inch away from the edge of the ulcer, the in- 
cision passing through the skin. After incision keep the part elevated 
and dressed antiseptically for two days. In two days after scarification 
or incision scrape the ulcer with a curet until sound tissue is reached. 




160 Ulceration and Fistula 

Use hot antiseptic fomentations for two days more, then paint the parts 
adjacent to the ulcer with tincture of iodin and alcohol (i 13), dress 
the parts about the ulcer with ichthyol ointment, and dress the ulcer anti- 
sepically or with sterile gauze. In a day or so the use of ichthyol can be 
discontinued and the ulcer can be dressed with sterile gauze, normal salt 
solution, boric acid, bichlorid of palladium, chlorin-water, a solution of per- 
manganate of potassium, sulphur, glutol, protonuclein, or bovinin. Glutol 
(formalin-gelatin) is very useful in some cases and so is protonuclein. When 
healing begins, treat as outlined for healing acute ulcer (page 158). 

Unna's dressing is satisfactory in many cases. It is applied as a fluid, 
painted on when hot. It solidifies on cooling and resembles rubber. The 
paint is made as follows: Dissolve 4 parts of the best gelatin in 10 parts of 
water by means of a hot-water bath. While the fluid is hot add 10 parts of 
glycerin, and then 4 parts of powdered white oxid of zinc and stir energetically 
until the mixture is cold. Melt the paint before using by placing the receptacle 
in a hot-water bath. The extremity must be clean and thoroughly dry. 
Apply the paint from just above the roots of the toes to just below the knee. 
Cover the layer of paint with a gauze bandage; put over this another layer of 
paint, then another bandage, and so on until three, four, or five bandages have 
been applied. To prevent wrinkling, put the bandages on in pieces. The 
outer layer of the dressing is a coat of the paint. This dressing is worn from 
four to eight weeks unless it loosens sooner. When it loosens, it is changed. 
If the ulcer discharges freely and stains the dressing, cut a trap-door in the 
dressing and through this cleanse the ulcer and apply dressings and a bandage 
as often as necessary (Michel, in "Chicago Clinic," No. 8, 1900). 

An excellent treatment if the patient must walk about is camphor, first 
recommended by Schulze (" Miinchener medicinische Wochenschrift, " March 
19, 1901). It is most conveniently used, as Walbaum shows, in the form of 
spirits of camphor (" Miinchener medicinische Wochenschrift, " June 25, 1901). 
He applies the dressing in the following manner: Clean the ulcer with green 
soap and dress it daily with dressings wet with a 2 per cent, solution of the 
acetate of aluminium. In about three days the discharge will become scanty 
and free from odor. It is at this period that camphor should be used. A 
small piece of gauze wet with spirits of camphor is applied directly and only to 
the ulcer. Over this is applied a large piece of dry sterile gauze, a rubber 
dam, a large piece of absorbent cotton, and a bandage from the toes up. 
Every other day the dressings are removed, the ulcer is washed with a 2 per 
cent, solution of carbolic acid, and the dressings are reapplied. Usually the 
ulcer is healed in three weeks. 

Complications. — Remove by scissors and forceps any badly damaged 
tissue. Take out dead bone; slit sinuses; trim overhanging edges. Treat 
eczema locally by washing with ethereal soap and applying powdered oxid 
of zinc or borated talcum, the leg then being wrapped in cotton. Unna's 
paint is very useful in chronic eczema. If the part is crusted, the crusts 
should be removed by applying some oily materials and washing with ethereal 
soap and water. Ordinary soap should not be used. In an acute case soap 
and water always do harm and the part is to be cleaned by "gently wiping 
with cold cream or petrolatum" (Stelwagon, on "Diseases of the Skin"). If 
crusting is very marked it may be necessarv to remove it by means of an ordi- 



Complications of Ulcers 



161 



nary pouitice, or, better, a starch poultice made with a 2 per cent, solution of 
boracic acid. When scales or crusts are slight or absent or when they have 
been removed, the remedial agent should be applied. The remedies for 
eczema are legion. Among them are a solution of lead acetate; lead-water 
and laudanum; a powder composed of 30 grains of powdered boracic acid 
and J ounce each of talc and zinc oxid; ung. picis liquidae, 5j\ w 'th sufficient 
ung. zinci oxidi to make §j; \ ounce of liquor carbonis detergens to 1 pint 
of water. In every case of eczema place the patient upon a plain and nutri- 
tious diet; order' him to avoid wines and liquors; give an occasional saline 
laxative; keep the skin and kidneys active, and if the patient is gouty or rheu- 
matic, give appropriate remedies. The value of arsenic in eczema has been 
much overrated. 

Varicose veins demand either ligation at several points, excision, Tren- 
delenburg's operation (page 396), circumcision by Schede's method (page 
397), or the continued use 
of a flannel roller or a 
Martin rubber bandage. 
Never operate on varicose 
veins if phlebitis exists, 
unless a clot has formed, 
in which case apply a liga- 
ture above the clot. In- 
flammation is met by rest, 
elevation, painting the 
neighboring parts with 
dilute tincture of iodin, 
and applying about the 
ulcer ichthvol ointment. 
For calloused edges, blister, 
employ radiating incisions, 
or cut the edges away. 
Ordinary thick edges should 
be strapped. In strapping 
use zinc oxid adhesive plas- 
ter and do not completely 
encircle the limb (Fig. 76). 
When the parts are adherent 

the ulcer is immovable, being firmly anchored to structures beneath it. In such 
a condition completely or partly surround the sore with a cut through the deep 
fascia (Fig. 75). This cut sets the ulcer free from its anchorage and per- 
mits it to contract. Edematous granulations require dry dressings and pres- 
sure by a flannel bandage, a rubber bandage, or adhesive plaster. If the 
bottom of the ulcer is foul, dry it and touch with a solution of acid nitrate 
of mercury (1 : 8) or with crystals of pure carbolic acid. Repeat this even- 
third day and dress with hot antiseptic fomentations until granulations appear. 
Superfluous granulations (proud flesh) should be cut away with scissors, 
scraped away, or burned down with a strong solution of silver nitrate, with the 
solid stick of lunar caustic, or, better, with pure carbolic acid which cause much 
less pain than does silver. Absence of granulations or scantiness of granula- 




Fig. 76.— Strapping an ulcer of leg (Keen's Surgery). 



1 62 Ulceration and Fistula 

tions means deficiency of blood-supply. The surgeon endeavors to bring 
more blood to the part, and to do this induces inflammation. The usual 
method of procedure is to apply daily to the sore a solution of nitrate of silver 
(10 or 15 grains to the ounce). Argyrol of a strength of 25 per cent, is not 
painful and is as efficient. In obstinate cases blister the ulcer or scrape it, or 
paint it with tincture of iodin, or apply pure carbolic acid, or touch it with 
the actual cautery. 

Irritable ulcer is due to exposure of a nerve and destruction of its sheath 
(page 163). Find with a probe the painful point and incise it with a teno- 
tome, or curet the ulcer or burn it with the solid stick of silver nitrate. 

If healing entirely fails, skin-graft. Among the methods of skin-grafting 
are — (1) Reverdin's, (2) Thiersch's, and (3) Wolfe's. (See Plastic Surgery.) 

When a man having an ulcer must go out and about, the camphor treatment 
can be employed (page 160), Unna's dressing may be applied (page 160), or 
the patient can use a firmly applied roller, or, better still, a Martin bandage. 
Martin's bandage, which is made of red rubber, limits the amount of arterial 
blood going to the ulcer and favors venous flow from the sore and its neigh- 
borhood. The bandage should be used as follows: Before getting out of bed 
spray the sore with hydrogen peroxid by means of an atomizer, remove the 
froth with absorbent cotton, wash the leg with soap and water, dry it with a 
towel, dust the skin with borated talcum powder, and apply the bandage. 
All of these things should be done before putting the foot to the floor. At 
night, after getting on the bed, remove the bandage, wash it with soap and 
water, dry it with a towel, hang it unrolled over the back of a chair to air, and 
again cleanse the leg and ulcer. If these rules are not strictly observed, the 
Martin bandage will produce pain, suppuration, and eczema of the leg. 

Tuberculous Ulcers (see pages 229, 230). 

Syphilitic Ulcers (see page 285). 

A healthy ulcer is covered with small, bright-red granulations which do 
not bleed on touching, are painless, and grow rapidly. The edges of the sore 
are soft and show the opalescent blue line of proliferating epithelium. The 
sore is movable, the discharge is purulent and yellow, and the parts about 
are not inflamed. 

Various Ulcers. — The fungous or exuberant ulcer is produced by 
interference with the return of venous blood from the part, and it is specially 
common after burns and other injuries when cicatricial contraction causes 
venous obstruction. The granulations are large, deep red in color, bleed 
when touched, form rapidly, and mount above the level of the skin. The 
discharge from a fungous ulcer is profuse, thin and bloody. In the treatment 
of such an ulcer venous return must be favored by bandaging and by elevation 
of the part. If the edges are very thick, divide them in a number of places. 
The superfluous granulations should be burnt down with lunar caustic or 
pure carbolic acid or should be cut off. Strapping with adhesive plaster or 
the use of a rubber bandage does good. The sore can be dressed with 
europhen, aristol, or dry aseptic gauze. 

A varicose ulcer is an ulcer complicated by varicose veins. It is usually 
single, is oval, round, or irregular in outline, and is most often seen above the 
inner malleolus. Its edges are thick, everted, and swollen. The swelling is 
largely due to edema, and is found to pit on pressure. The edges are not 



Callous Ulcer 163 

undermined, but slope gently to the floor of the ulcer. The floor is usually 
covered with rather large granulations which bleed freely on touching. In a 
varicose ulcer the destruction of tissue often begins at the margin of a con- 
gested area and advances toward the center. Such an ulcer is usually sur- 
rounded by eczema. To aid the healing of a varicose ulcer it is first of all 
necessary to favor the return of venous blood from the part by position and 
bandaging. Martin's bandage is very useful. It may be necessary to operate 
on the veins. 

Erethistic, irritable, or painful ulcers are very sensitive, a condition 
due to the exposure of nerve-filaments and destruction of nerve-sheaths. 
Irritable ulcers are especially found near the ankle, over the tibia, in the anus 
(fissure), or in the matrix of the nail (ingrowing nail). Fissure of the anus 
is considered on page 1012. An ingrowing nail is sometimes encountered on 
the finger but far more commonly affects the toe. The great toe is especially 
apt to suffer. We call it ingrowing nail but the condition is reallv overgrowing 
skin. As a result of wearing ill-fitting boots or stockings, especially shoes 
which are too short or are pointed, the toes are forced together and the skin 
at the edge of the nail is pushed open. After a time an ulcer forms. 

When a nail begins to ingrow the condition can usually be arrested by 
wearing well-fitting shoes and stockings, allowing the nail to grow somewhat 
long and cutting it square across instead of cutting away the troublesome 
corner. Daily a little absorbent cotton should be packed under the ingrowing 
corner. In more severe cases under local anesthesia, cut away the overlap- 
ping skin and a portion of the flesh on the side of the toe, split the nail lon- 
gitudinally, remove the ingrown portion of nail and a corresponding part of 
the matrix. 

An erethistic ulcer of the cutaneous surface is treated as follows: Curet 
and touch with pure carbolic acid or with the solid stick of silver nitrate. 
Chloral, gr. xx to the ounce, allays the pain; so do cocain and eucain for a 
time. In some cases the painful area can be located with a probe and the 
nerve-filament divided with a tenotome. 

The indolent ulcer shows no tendency to heal. In such an ulcer there 
is usually venous congestion from varicose veins or from cardiac weakness. 
A great mass of scar-tissue forms at the base and edges, which fastens the 
ulcer to bone or fascia, so that the edges cannot contract. Healthv granula- 
tions cease to form. The edges of such an ulcer are thick, smooth, immovable, 
and free from tenderness. Granulations are entirely absent or there are seen 
here and there a few unhealthy granulations. The discharge is thin, sero- 
purulent, and offensive. The parts about the ulcer are congested and pig- 
mented. The pigmentation is due to the fact that in the area of chronic 
congestion numbers of red blood-cells have been disintegrated. Such an 
ulcer is treated by making incisions to loosen the base and edges, so that con- 
traction can take place. Venous congestion is corrected by means of posi- 
tion, the use of compression, and in some cases the administration of cardiac 
stimulants. In all cases the surgeon employs stimulating applications to the 
ulcer in order to increase the supply of arterial blood. 

The callous ulcer is the most chronic form of indolent ulcer and is sunken 
deeply below the level of the skin. Its border is hard and knobby. Its floor 
shows no granulations, and is either smooth and glistening or foul and liver- 



164 Ulceration and Fistula 

colored. The discharge is thin and scanty, and the ulcer varies little in 
appearance from week to week or even from month to month. The treat- 
ment consists in scraping and cauterizing the ulcer; making radiating inci- 
sions through the margins and floor or elliptical incisions about the ulcer; 
applying antiseptic dressings and a firm bandage. In some cases the ulcer 
should be strapped. In severe cases it is necessary to extirpate the ulcer and 
apply skin-grafts. 

Hemorrhagic ulcers bleed easily and profusely. Pressure must be 
applied; it is sometimes necessary to cut or burn away the granulations. 

Phagedenic Ulcers. — The phagedenic ulcer results from the profound 
microbic infection of tissues debilitated by local or constitutional disease, and 
is commonly venereal. This ulcer has no granulations and is covered with 
sloughs; its edges are thin and undermined, and it spreads rapidly in all 
directions. Such an ulcer should be touched with strong caustics or Paque- 
lin's cautery, and dressed with iodoform gauze and antiseptic fomentations. 
Tonics and stimulants should always be administered. 

The edematous ulcer may result from impediment to the venous return 
or, as Xancrede points out, may be produced by the persistent use of poultices 
or wet dressings upon any ulcer.* It is most often met with in tuberculous 
processes and is occasionally seen when varicose veins exist. The granula- 
tions are large and pale, and are apt to bend over like unsupported vines. 
The discharge is profuse and seropurulent. The edges are softened and 
desquamating. An edematous ulcer requires dry dressings, stimulation, and 
compression. 

A rodent or Jacob's ulcer, noli me tangere, or cancroid ulcer, is a 
superficial epithelioma developing usually from sebaceous glands, sweat- 
glands, or hair follicles. It requires scraping and cauterization, or, what is 
better, excision (page 334). 

Marjolin's ulcer (Fig. 77) is an epithelioma arising from a chronic ulcer 
or an old cicatrix. The malignant change begins at some point of the edge of 
the ulcer, and its first evidence is induration. The induration spreads slowly 
and comes to involve a considerable part of or even the entire ulcer. Marjolin's 
ulcer is the seat of scalding, darting pain; the discharge is profuse, ichorous, and 
foul, and the floor of the ulcer is uneven, warty, or cauliflower-like. The ana- 
tomically related lymph-glands eventually become involved. This involve- 
ment is rarely early because induration has blocked lymph-channels. In 
order to confirm the diagnosis a bit of tissue should be removed and the 
removed piece must include a portion of the* edge of the ulcer and of some 
apparently sound tissue beyond it. If a microscopical examination shows 
epithelial infiltration of the apparently sound tissue, a diagnosis of malignant 
disease must be made. In an early stage of such an ulcer free extirpation 
and removal of the anatomically related glands may cure the patient. In 
a more advanced case, if an extremity is involved, amputate and clear out the 
related lymphatic area. In a very advanced case use the -r-rays. 

Decubitus, or bed-sore, is due to pressure upon an area of feeble circu- 
lation (page 182). It is in most instances a condition of gangrene. 

Neuroparalytic or trophic ulcer, is due to impairment of the trophic 
nerve-fibers or of the trophic centers in the cord. 

♦"Principles of Surgery." 



Perforating Ulcer 



165 



The perforating ulcer, as it was named by Yesigne, is believed to result 
from peripheral neuritis. It is certain, however, that in some of these cases 
there is arteriosclerosis and it has been held that the vascular sclerosis is the 
real cause and that the nerve changes are secondary to the vascular changes. 
My own belief is that perforating ulcer is a condition dependent upon both ar- 
teriosclerosis and peripheral neuritis, traumatism usually being the exciting 
cause of the ulcer. It is met with most frequently in diabetics, but may be en- 
countered in the victims of chronic alcoholism, injuries and diseases of the spinal 
cord, injuries and diseases of nerves, Bright's disease, and syphilis. I have 
seen this ulcer in an individual with a fractured spine, in two tabetics, 
and in several diabetics. The perforating ulcer commonly affects the 
plantar surface of the metatarsophalangeal joint or the pulp of the great 
toe or little toe about a callosity or corn. It may arise on the heel or 
the sole or the side of the foot. It is usually unilateral but sometimes 



> 

Mmftt. fmm 




^^W 


^SL-^^B 






** m 





Fig. 77. — Marjolin's ulcer. 



both feet are affected. Very rarely it affects the palm of the hand. The 
parts about the corn inflame, and pus forms and reaches into the bone. 
A sinus evacuates the pus by the side of the corn or callosity or the 
center of the callosity exhibits a blister containing sero-pus. A portion 
of the callous mass is cast off and a shallow ulcer is often exposed. This 
ulcer is small, has a punched-out appearance, and is surrounded bv cal- 
loused margins. The ulcer penetrates deeply and after a time the bone is laid 
bare or the joint opened. The margins of the ulcer or sinus exhibit sprout- 
ing granulations and these are encircled by an area of markedly thickened 
epidermis. In very rare cases more than one ulcer is present on the foot. The 
discharge from a perforating ulcer is thin and scanty and the ulcer, which 
slowly advances, is very chronic. It is not painful and is slightly, if at all, 
tender. The foot is cold and often edematous and the parts about the ulcer 
may be anesthetic. The ulcer may heal when the patient is kept in bed and 
open again when he gets about. The disease is far more common among 



166 Ulceration and Fistula 

males than among females and is most often met with in the fourth or fifth 
decades of life. As this ulcer may be present in anesthetic leprosy, in diabetes, 
peripheral neuritis, syphilis, in a paralyzed limb, and tabes dorsalis, and as 
the part on which it occurs is apt to be sweaty, cold, and more or less anesthetic, 
and as the sore may be hereditary, it is usually set down as trophic in origin. 
In treatment of a perforating ulcer I follow the plan suggested by Treves. 
This consists in putting the patient to bed and applying poultices to 
the sore. Every time a poultice is removed the raised epithelium around 
the ulcer is cut away and then the poultice is reapplied. In about two 
weeks an ulcer remains surrounded by healthy tissue. Treves treats this 
sore with glycerin made to a creamy consistency with salicylic acid, to each 
ounce of which mixture nix of carbolic acid have been added. He directs the 
patient to wear during the rest of his life some form of bunion-plaster to 
keep off pressure. If in a perforating ulcer the bone is diseased, it must be 
removed. If the patient is diabetic he must be placed on antidiabetic diet and 
drugs. Nerve-stretching has been recommended as the proper treatment for 
perforating ulcer, but I have never tried it. No matter what treatment is 
employed, the sore is apt to reappear in the old situation or an adjacent 
region, when the part is subjected to pressure. In order to prevent pressure 
upon the region of ulceration some advise the use of an artificial leg, the knee 
being kept bent. It may be necessary to amputate the toe or the foot. 

The scorbutic ulcer is covered with a dark-brown crust, beneath which 
are pale and bleeding granulations. The parts adjacent are of a violet color. 

Epitheliomatous, sarcomatous, tuberculous, and syphilitic ulcers and ulcers 
of the stomach and duodenum are considered under these respective diseases. 

Curling's Ulcer. — This is an ulcer of the first portion of the duodenum 
which in rare cases follows an extensive burn of the cutaneous surface. It is 
small, clean cut, and deep and is due to embolism, the emboli being hyaline 
material precipitated from the blood. The treatment is gastroenterostomy. 
If perforation occurs the treatment is as for any other perforating duodenal 
ulcer. 

Fistula. — A fistula is an abnormal communication between the surface 
and an internal part of the body, or between two natural cavities or canals. 
The first form is seen in a rectal fistula, a urethral fistula, or a biliary fistula; 
and the second form is seen in a vesicovaginal fistula. Fistulae may result 
from congenital defect, as when there is failure in the closure of the branchial 
clefts, and can arise from sloughing, traumatism, and suppuration. Fistulae 
are named from their situation and communications. For instance, a pleural 
fistula, an intestinal or fecal fistula, a rectal fistula, an anal fistula, a gastric 
fistula, a bronchial fistula, a vesical fistula, a biliary fistula, etc. Many fis- 
tula; are tuberculous and lead to some deeply placed tuberculous focus. A 
fistula in communication with a viscus (for instance, the gall-bladder) may be 
maintained by an obstruction of the duct of that viscus the removal of which 
cures the fistula. 

A sinus is a tortuous track opening usually upon a free surface and leading 
down into the cavity of an imperfectly healed abscess. A sinus may be an 
unhealed portion of a wound. Many sinuses are due to pus burrowing sub- 
cutaneously. A sinus fails to heal because of the presence of some irritant 
fluid, as saliva, urine, or bile; because of the existence of a foreign body, as 



Fistula — Sinus 167 

dead bone, a bit of wood, a bullet, a septic ligature, etc.; or because of rigidity 
of the sinus-walls, which rigidity will not permit collapse. Sinuses may be 
maintained by want of rest (muscular movements) and general ill health. 
The walls of a tuberculous sinus are lined with a material identical with the 
Volkmann's membrane of a cold abscess. 

Treatment. — In treating a fistula or a sinus, remove any causative 
obstruction and any foreign body, lay the channel open, curet, brush with 
pure carbolic acid, and pack with iodoform gauze. In obstinate cases entirely 
extirpate the fibrous walls, sew the deeper parts of the wound with buried 
catgut sutures, and approximate the skin surfaces with interrupted sutures 
of silkworm-gut. To stimulate a sinus to granulation it is sometimes neces- 
sary to touch it throughout with the actual cautery, nitric acid, pure carbolic 
acid, nitrate of silver fused on a metallic probe, or in a solution of a strength 
of gr. xl to the ounce, or argyrol of a strength of 50 per cent. Fresh air is 
a necessity to the patient, and nutritious food and tonics must be ordered. 



168 Mortification, Gangrene, or Sphacelus 



VIII. MORTIFICATION, GANGRENE, OR SPHACELUS. 

Mortification, or gangrene, is death in mass of a portion of the living body 
— the dead portions being large enough to be visible — in contrast to ulceration, 
or molecular death, in which the dead particles have been liquefied, cannot 
be seen, and are cast away. When all the tissues of a part are dead, the pro- 
cess is spoken of as sphacelus. Gangrene is in reality a form of necrosis, 
but clinically the term necrosis is restricted to molar death of bone or to death 
of parts below the surface en masse. In gangrene a portion of tissue dies 
because of anemia, and the dead portions may either desiccate or putrefy. 
Gangrene may be due to tissue injury, either chemical or mechanical, to heat 
or cold, to failure of the general health, to circulatory obstruction, to nerve 
disorder, the nerves involved being the vasomotor or possibly the trophic, or 
to microbic infection. A microbic poison can directly destroy tissues. It 
can indirectly destroy them by causing such inflammation that the products 
obstruct the circulation, but gangrene can occur when no bacteria are present. 
The essential cause of gangrene is that the tissues are cut off from a due supply 
of nourishment, and cell-nutrition is no longer possible. In other words, 
the essential cause of gangrene is the cutting off of arterial blood. Nancrede 
says: "Indeed, except when the traumatism physically disintegrates tissues, 
as a stone is reduced to powder, heat or strong acids physically destroy struc- 
ture, or cold suspends cellular nutrition so long that when this nutrition be- 
comes a physical possibility vital metabolism cannot be resumed, gangrene 
always results from total deprivation of pabulum." * 

Classification. — Gangrene is divided into the following three great 
groups: 

(i) Dry gangrene, which is due to circulatory interference, the arterial 
supply being decreased or cut off. The tissues dry and mummify. 

(2) Moist gangrene, which is due to interference not only with arterial 
ingress, but also with venous return or capillary circulation, the dead parts 
remaining moist. 

(3) Microbic gangrene, arising from virulent bacteria. In this form 
the bacterial process causes the gangrene, and is not merely associated with it. 

The above classification, if unqualified, suggests erroneous ideas. It in- 
dicates that there is an essential difference between dry gangrene and moist 
gangrene, which is not the case. If, when gangrene begins, the tissues are 
free from fluid, the patient develops dry gangrene; if they are full of fluid, he 
develops moist gangrene. If the arterial supply is gradually cut off, the tissues 
are sure to be free from fluid, and the gangrene will certainly be of the dry 
form. If arterial blood is suddenly cut off, the gangrene may be dry or moist, 
according as to whether the tissues are or are not drained of fluid. When 
gangrene results from inflammation, strangulation, and infection, it is certain 
to be of the moist variety, because the tissues are sure to be filled with fluid. 

Nancrede says, in his very valuable work on the "Principles of Surgery": 
"Yet, let accidental inflammation have preceded the final blocking of an 
artery, or let ligation of the main artery cause gangrene because the collateral 

*" Principles of Surgery." 



Non-senile Dry Gangrene 169 

circulation cannot become developed, and if an aneurysmal sac is so situated 
as to interfere with a free return of venous blood and lymph, this anemic- 
gangrene will in both instances prove moist and not dry." 

There are many gangrenous processes which belong under one or other 
of the above heads, namely: congenital gangrene, a rare form existing at birth; 
constitutional gangrene, arising from a constitutional cause, as diabetes; 
cutaneous gangrene, which is limited to skin and subcutaneous tissue, as in 
phlegmonous ervsipelas; gaseous or emphysematous gangrene, in which the 
subcutaneous tissues are filled with putrefactive gases and crackle on pressure; 
hospital gangrene, which is defined by Foster as specific serpiginous necrosis, 
the tissues being pulpefied : some consider it a traumatic diphtheria ; cold 
gangrene, a form in which the parts are entirely dead (sphacelus) ; hot gan- 
grene, which is associated with inflammation, as shown by heat; dermatitis 
gangrenosa infantum, or the multiple cachectic gangrene of Simon; idiopathic 
gangrene, which has no ascertainable cause; mixed, which is partly dry and 
partly moist; primary, in which the death of the part is direct, as from a burn; 
secondary, which follows an acute inflammation; multiple, as gangrenous 
herpes zoster; diabetic or glycemic gangrene, which arises during the existence 
of diabetes; gangrenous ecthyma, a gangrenous condition of ecthyma ulcers; 
pressure, which is due to long compression; purpuric or scorbutic, which is 
due to scurvv; Raynaud's or idiopathic symmetrical, which is due to vascular 
spasm from nerve disorder; senile, the dry gangrene of the aged; venous or 
static, which is due to obstruction of circulation, as in a strangulated hernia; 
trophic, which is due to nutritive failure by reason of disorder of the trophic 
nerves or centers; thrombotic, which is due to thrombus; embolic, which is due 
to embolus; and decubitus, decubital gangrene, or bed-sores due to pressure. 

Dry gangrene arises from deficiency of arterial blood. For this reason 
Nancrede calls it anemic gangrene. 

This form of gangrene is far more apt to result from the gradual than from 
the sudden cutting off of the supply of arterial blood, and is more common if 
the blood-vessels are atheromatous than if they are healthy; but even in a 
person with healthy arteries gangrene will ensue upon blocking of the main 
arterv, if the collaterals fail to supply the part with blood. This form of 
gangrene can occur after laceration, ligation, or the lodgment of an embolus 
in the main artery of a limb; but in such accidents considerable fluid usually 
remains in the tissues and the gangrene is apt to be moist rather than dry. 

Non-senile Dry Gangrene. — An embolus may cause dry gangrene in 
rare instances. If it does so, it is probable that the blocking was not at once 
complete. When an embolus lodges in an artery and causes dry gangrene, 
the case runs the following course: sudden severe pain at the seat of impaction,. 
and also tenderness; pulsation above, but not below, this point, after obstruc- 
tion has become complete; the limb below the obstruction is blanched, cold, 
and anesthetic; within forty-eight hours, as a rule, the area of gangrene is 
widespread and clearly evident; the limb becomes reddish, greenish, blue, 
and then black; the skin becomes shriveled and its outer layer stony or like 
horn because of evaporation. The entire part may become dry; but usually 
there are spots where some fluid remains, and these spots are soft and moist, 
and the dead tissue, where it joins the living, is sure to be moist. The moist 
areas become foul and putrid, but the dry spots do not. In dry gangrene, at 



170 



Mortification, Gangrene, or Sphacelus 



the point of contact of the dead and living tissues, inflammation arises in the 
latter structures, a bright-red line forms, and exudation and ulceration take 
place. This line of ulceration in the sound tissues is called the " line of de- 
marcation." It is Nature's effort at amputation, and in time may get rid of a 
large portion of a limb, and then heal as any other ulcer. A line of demarca- 
tion rarely causes hemorrhage, because it ulcerates through a vessel only after 
inflammation has caused occlusion by thrombosis. In dry gangrene from 
arterial obstruction there is gastro-intestinal derangement and also some fever. 
The gangrene does not extend up to the point of obstruction, but only to a 
region in which the anastomotic circulation is sufficiently active to permit of 
the formation of a line of demarcation. Below this point inflammatory stasis 
arises, but before this can go on to ulceration the parts die. In cases where the 
arterial obstruction is sudden and complete the limb swells decidedly. This is 
due to the sudden loss of vis a tergo in the arterial system, venous reflux occur- 
ring and fluids transuding. In such a case the tissues contain fluid and putrefy, 
and the process, though due to the cutting off of the arterial circulation, is 
moist gangrene. Dry gangrene attacks the leg more often than the arm. 
A thrombus in an artery rarely causes gangrene except in the aged, as the 
collateral circulation has time to adjust itself; but gangrene may follow 
thrombus formation, and when it does it comes on more slowly than does gan- 
grene from embolus, and is certain to be of the dry form. 

Treatment of Non-senile Dry Gangrene. — When injury or blocking of a 
healthy artery causes us to fear the onset of dry gangrene, the patient should 
be placed in bed and the part elevated a little, kept wrapped in cotton-wool 
and surrounded with bottles filled with warm water. If gangrene begins, wait 
for a line of demarcation, and while waiting dress the dying and dead parts 
antiseptically, wrap the extremity in cotton and keep it warm, and see to it 
that the patient gets plenty of sleep and nourishment. It is also advisable to 
give tonics and stimulants. When a line of demarcation forms, amputate well 
above it. 

Senile gangrene, chronic gangrene, Pott's gangrene (Fig. 78), is a 
form of gangrene due to feeble action of the heart plus obliterating endarteritis 

or atheroma of periph- 
eral vessels. The ves- 
sels do not carry a nor- 
mal amount of blood, 
and may at any time be 
occluded by thrombosis. 
In a drunkard, or in a 
victim of syphilis or tu- 
bercle, the changes sup- 
posed to characterize old 
age may appear while a 
man is young in years. 
It wa*s long ago said, 
Senile gangrene most often 




Senile gangrene of the feet (Gross). 



old as his arteries. 



with truth, "a man is as 
occurs in a toe or the foot. 

Symptoms. — A man whose vessels are in the state above indicated is gener- 
ally in feeble health and has a fatty heart and an arcus senilis (a red or white 



Senile Gangrene 



171 



line of fatty degeneration around the cornea). His toes and feet are cold and 
feel numb, and they "go to sleep" very easily, and he suffers from cramp of the 
legs and feet. He is dyspeptic and short of breath, and his urine is frequently 
albuminous. The arteries are felt as rigid tubes, like pipe-stems. He is in 
danger of edema of the lungs and of dry gangrene of the toes. A slight injury 
of a toe — for instance, cutting a corn too close — will produce extensive in- 
flammatory stasis followed by thrombosis, which completely cuts off the blood- 
supply and causes gangrene of the part. Gangrene is usually announced by 
the appearance of a purple and anesthetic spot followed by a vesicle which 
ruptures and liberates a small amount of bloody serum and exposes a dry 
floor. In the parts about the gangrenous area there is often burning pain. 
The circulation in the tissues immediately adjacent to the dead spot is retarded 
or stagnated, the parts being purple and the color not disappearing or dis- 
appearing slowly under pressure. If the color fades under pressure it 
returns slowly when pressure 
is removed. The parts a little 
further removed are hypere- 
mic, the color disappearing 
rapidly on pressure, and re- 
turning rapidly when pres- 
sure is removed. The dead 
parts do not putrefy at all or 
do so but slightly, hence the 
odor is never very offensive 
and is usually trivial. They 
are anesthetic, hard, leathery, 
and wrinkled, and resemble a 
varnished anatomical speci- 
men or the extremity of a 
mummy (hence the term mum- 
mification). Before the line 
of demarcation forms there 
is burning pain ; after it forms 
pain is rarely present. If em- 
bolism or thrombus in a dis- 
eased vessel caused the gangrene, the pain is severe at the point of im- 
paction. In senile gangrene the distal portion of the dead area is always 
dry, the part nearer the body being generally somewhat moist. The process 
may be very limited or it may spread up to the knee. As it spreads the area 
of hyperemia advances at the margin, the area of stasis follows, and the 
zone of gangrene becomes more extensive. When tissues are reached, the 
blood-supply of which is sufficiently good to permit of inflammation going be- 
yond the stage of stasis and to allow of stasis without extensive thrombosis, 
Nature tries to limit the gangrene by the formation of a line of de- 
marcation. A line of demarcation may begin, but prove abortive, the 
tissue mortifying above it. This proves that tissue near the line is in 
a state of low vitality. The line of demarcation may prove durable 
and in some few cases spontaneous amputation takes place (Fig. 79). 
When a limited area is gangrenous, constitutional symptoms are trivial or 




Fig. 79. — Dr. Keller's case of spontaneous amputation of a 
foot and part of a leg in a condition of senile gangrene. 



172 Mortification, Gangrene, or Sphacelus 

absent; but when a large area is involved, the fever of septic absorption exists. 
Death may ensue from exhaustion caused by sleeplessness and pain, from 
septic absorption, or from embolism of internal organs. In many cases of 
senile gangrene clots are formed in the superficial femoral artery or its branches 
(Heidenhain), an observation it is important to bear in mind when am- 
putating. 

Prevention of Senile Gangrene in the Predisposed. — Such a patient must 
avoid injuring his toes and feet. Cutting his corns carelessly is highly dan- 
gerous, and any wound, however slight, requires rest and antiseptic dressing. 
The victim of general atheroma must wear woolen stockings, put a rubber 
bag containing warm water to his feet on cold nights, and attend to his gen- 
eral health. A little whiskey after each meal is indicated, and occasional 
courses of nitroglycerin are desirable. 

Treatment of Senile Gangrene. — When gangrene occurs, if it is limited to 
one toe or a portion of several toes, if it is a first attack, if there is no fever or 
exhausting diarrhea, if there is no tendency to pulmonary congestion, if the 
appetite is fair and sleep refreshing, it is best to avoid radical interference 
and to await the formation of a line of demarcation. While awaiting the line 
of demarcation dress the part antiseptically, raise the foot several inches 
from the bed and surround the part with bottles of moderately warm water. 
Very warm water may do harm. Give the patient nourishing diet, stimulants, 
and tonics; see to it that he sleeps, and during the spread of the gangrene 
watch for fever, diarrhea, pulmonary congestion, and kidney failure. When 
a line of demarcation forms, dress with warm antiseptic fomentations and 
iodoform, and every day pick away dead bits with the scissors and forceps. 
A tendon or ligament should be cut through and a protruding phalanx should 
be divided with a Gigli saw. If an ulcer forms skin-grafts may be applied. 
In many cases healing will occur; but even when the parts heal, the patient 
will always be in deadly peril of another attack. If the gangrene shows a. 
tendency to spread, if it involves more than a portion of several toes, if it is 
not a first attack, if there is sleeplessness, fever, exhausting diarrhea, anorexia, 
or a strong tendency to pulmonary congestion, do not delay j but at once am- 
putate high up. If the gangrene shows no tendency to limit itself, or if the 
patient develops sepsis or exhaustion, at once amputate high up. The best 
point at which to amputate is above the knee, so that the deep femoral artery, 
which rarely becomes atheromatous, will nourish the flap and gangrene will 
not occur. It has been pointed out that the superficial femoral artery and its 
branches often contain a clot. Never amputate below the tubercle of the tibia. 
Some operators disarticulate at the knee-joint. Heidenhain affirms that so 
long as the gangrene is limited to one or two toes we should merely treat it 
antiseptically, elevate the limb, and wait for the dead part to be cast off spon- 
taneously, if, however, it extends to the dorsum or sole of the foot, we should 
amputate at once above the knee. He further states that gangrene of the 
flaps almost always occurs in amputations below the knee, and high amputa- 
tion is indicated in advancing gangrene with or without fever.* When am- 
putation has been performed and the Esmarch band has been removed and 
no arterial bleeding takes place from the superficial femoral artery, a clot is 
lodged in that vessel. If such a condition exist, insert into the artery a fine 
* Deutsche medicinische Wochenschrift, 1891, p. 1087. 



Moist Gangrene from Inflammation 



173 




-Acute gai 



(Gross 1. 



rubber catheter or a filiform bougie and break up the clot. When blood flows 
we are sure that the clot has been washed out.* 

Moist or Acute Gangrene.— In moist or acute gangrene (Fig. 80) the 
dead part remains moist 
and putrefies. As Nan- 
crede points out, there 
are two forms of moist 
gangrene : ' ' that limited 
to the areas actually 
killed by a traumatism, 
with some surrounding 
tissue which dies," and 

"that which tends to spread widely, this latter being usually caused by specific 
micro-organisms, an intense, widespread, pyogenic inflammation resulting, in- 
volving the subcutaneous and intermuscular cellular planes, by strangulation of 
the vessels by which all blood -supply to the remaining soft parts is destroyed." f 
In a case of moist gangrene the parts remain moist, either because the main artery 
has become suddenly blocked, and the tissue fluids are not urged by sufficient 
vis a tergo to cause them to flow out of the limb, or because the main vein is 
blocked. It may arise in a limb after ligation, obstruction, or destruction 
of its main artery, main vein, or both; after long constriction, as by a tight 
bandage; after crushes and lacerated wounds; and after thrombosis of the 
vein. Moist gangrene may follow severe pyogenic infection, or may be due to 
local constriction (strangulated hernia), crushing, chemical irritants, heat, and 
cold. 

Moist gangrene of a limb may be seen typically in certain cases in 
which the main vein or artery or both vein and artery are constricted, dam- 
aged, or destroyed. The leg swells greatly and is pulseless below the obstruc- 
tion; the skin, at first pale, cold, and anesthetic, becomes livid, mottled, purple 
or greenish. A greenish color signifies putrefaction. Blebs are formed which 
contain a reddish or brown fluid. "These blebs, being caused by the accumu- 
lation of serum beneath epithelium which has lost its vital connection with the 
derm, can be slipped around upon the surrounding true skin, the epithelium 
readily separating for long distances around, as in a cadaver" (Nancrede). The 
extremity swells enormously, there may be pain at the seat of obstruction, but 
there is no pain in the gangrenous area, and sapremic symptoms quickly develop. 
The bullae break and disclose the brown derm and sometimes the deeper 
structures, which are swollen and edematous. The fetor is horrible. Slight 
or moderate fever usually exist. In mild cases a line of demarcation soon 
forms. In severe cases in which virulent saprophytes are present the process 
spreads with great rapidity, neighboring glands enlarge, the temperature is 
much elevated, no line of demarcation forms, there is profound exhaustion, 
and gases of decomposition accumulate in and distend the tissues and cause 
crackling when the parts are pressed upon. Such severe cases are in reality 
examples of foudroyant or emphysematous gangrene. 

Moist gangrene from inflammation is due to pressure of the exudate 

*Severeanu. See Ma ncozet's report before the Second Pan-American Medical Con- 
gress. 

t Nancrede's " Principles of Surgery." 



174 Mortification, Gangrene, or Sphacelus 

cutting of the blood-supply, or to loss of blood-circulation because of microbic 
involvement of vessels and clotting of blood. It occurs typically in phleg- 
monous erysipelas. When an inflammation is about to terminate in gangrene 
all the signs of inflammation, local and constitutional, increase; swelling 
becomes very great and may be due partly to fluid and partly to gas. If gas 
is present pressure will cause crackling. The color becomes livid or purple. 
The anatomically related glands are enlarged and the symptoms of sapremia 
or suppurative fever exist. When gangrene is actually present, the signs of 
inflammation have passed away, bullae and emphysema are noted, with great 
swelling and all the other symptoms of molar death. The sudden cessation 
of pain is very suggestive of gangrene. The constitutional symptoms are 
those of suppurative fever and sapremia, or possibly of septic infection. 

When a wound becomes gangrenous the surface looks like yellow or gray 
tow, the discharge becomes profuse and very fetid, and the parts about swell 
enormouslv and gradually become gangrenous. 

Treatment of Moist Gangrene. — In extensive moist gangrene of a limb, if 
the condition is of the form described as mild, in which there are not severe 
symptoms of sepsis and in which the gangrene is not rapidly progressive, 
wait for a line of demarcation, and amputate clear of and above it. While 
waiting for the line to form, dress the dead parts antiseptically, wrap the ex- 
tremity in cotton, apply warmth, and slightly elevate the limb. Give opium, 
tonics, nourishing food, and stimulants. In the severe form of moist gangrene 
(really foudroyant gangrene), amputate at once high above the gangrenous 
process. In inflammatory gangrene, such as is sometimes associated with 
phlegmonous erysipelas, relieve tension by incisions, cut away the dead parts, 
brush the raw surface with pure carbolic acid, dust with iodoform, and dress 
with hot antiseptic fomentations. Stimulate freely, administer nourishment 
at frequent intervals, and treat the patient in general as we would a case of 
sapremia, or suppurative fever. A gangrenous wound is treated as pointed 
out in the section on Sloughing. 

Acute microbic gangrene, fulminating gangrene, emphysematous 
gangrene, gaseous phlegmon, gangrenous emphysema, gangrene 
foudroyante, or traumatic spreading gangrene, results from a virulent 
infection of a wound. It was first described in 1853 by Maisonneuve under the 
name of gaseous phlegmon. The condition may be due to a mixed infection 
with virulent streptococci and organisms of putrefaction; or to infection with 
the bacilli of malignant edema, and putrefactive organisms. Some case are due 
to the bacillus of malignant edema alone; some are due to the bacillus a'crogenes 
capsulatus of Welch and Flexner. These gas bacilli are found in soil in 
animal and human feces, in street dirt, and the dust of floors. The injury is 
usually severe — often a crush which destroys the main artery and renders an 
anastomotic circulation impossible, sometimes a compound fracture or a gun- 
shot wound. In such severe accidents the limb is much swollen and the pulse 
below the seat of injury is imperceptible, and the surgeon is often at this time 
uncertain whether to amputate at once or wait. Emphysematous gangrene is 
commonest after compound fractures, and begins within forty-eight hours of 
the accident. The extremity becomes enormously swollen from edema and 
gas. The gangrene does not begin at the periphery, as does ordinary moist 
gangrene, but at the wound edges, which turn red, green, and finally black; 



Hospital Gangrene 175 

the extremity soon undergoes a like change and becomes mortified. The skin 
peels off, emphysematous crackling, due to gas formed and retained in the 
tissues, can be detected over large areas, and the extremity becomes anesthetic 
and pulpy. The gases formed in the tissues are sulphid of hydrogen, sulphid 
of ammonium, volatile fatty acids, and ammonia. Great fetor is soon noted. 
The gangrene spreads up and down from the wound, and red lines, due to 
lymphangitis, run from above the wound. The adjacent lymph-glands swell, 
and in thirty-six hours the gangrene may involve an entire limb. No line of 
demarcation forms. The system is soon overwhelmed with ptomai'ns, and 
the patient suffers from putrid intoxication, with delirium, and often passes 
into profound collapse with coma and subnormal temperature. Traumatic 
spreading gangrene must not be confused with erysipelas. In erysipelas the 
color is red, pressure instantly drives it out, and on the release of pressure it 
at once returns. In early gangrene the color is purple, pressure fails to drive 
it out at all or only does so very slowly, and if the surface is blanched by pres- 
sure, on the release of pressure the color crawls slowly back. Sometimes 
emphysematous gangrene, in the form of gangrenous cellulitis, follows a 
trivial injury such as a puncture, the entrance of a splinter, an abrasion, or 
a slight cut. The region about the injury becomes red, then livid, and finally 
green or black. Enormous swelling takes place, partly due to edema, partly 
to gas, and the swelling and discoloration spread rapidly. Red lines subse- 
quently becoming greenish run toward enlarged lymphatic glands above the 
gangrenous part. The tissues are rapidly separated and destroyed and the 
bone is often quickly exposed and infected. The symptoms point to over- 
whelming sepsis. There is high fever and delirium, and coma and death 
are apt to ensue. The patient may die in from twenty-four to forty-eight 
hours. Welch estimates the mortality from gaseous phlegmon at almost 60 per 
cent. 

Treatment. — In acute spreading gangrene of an extremity following a 
severe injury no delay is admissible. To wait for a line of demarcation is to 
expect the impossible, and a delay dooms the patient inevitably to death. 
Amputation must be performed at once high up, the flaps should be brushed 
with pure carbolic acid, and then every effort is to be made to sustain the 
patient's strength by the administration of food and stimulants. Antistrep- 
tococcic serum may possibly be useful. In cases of acute spreading gangrene 
following trivial injuries it may be possible to arrest the process by free in- 
cisions, thorough drainage, hot antiseptic fomentations, the continuous hot 
bath, or continuous antiseptic irrigations, stimulants, etc., but in some cases 
amputation is necessary. Some surgeons, notably Doerfler (" Miinchener 
medicinische Wochenschrift," April 23 and 30, 1901), oppose amputation in 
cases of spreading gangrene following trivial or moderately severe injury. 
Doerfler maintains that cases which recover after amputation would have 
recovered if amputation had not been performed. From this positive state- 
ment I am obliged to dissent. 

Hospital gangrene or sloughing phagedena is a disease that has prac- 
tically disappeared from civilized communities. It formerly occurred in 
crowded, ill-ventilated hospitals. Some consider it traumatic diphtheria. 
Koch thinks it is due to streptococci. Jonathan Hutchinson says: "Hospital 
gangrene is set up by admitting to the wards a case of syphilitic phagedena." 



176 Mortification, Gangrene, or Sphacelus 

It may show itself as a diphtheritic condition of a wound, as a process in which 
sloughs which look like masses of tow form, or as a phagedenic ulceration. 
The surrounding parts are inflamed and painful, and buboes form in adjacent 
lymphatic glands. The system passes into a low septic state. 

Treatment. — In treating hospital gangrene ether should be given, the large 
sloughs removed with scissors and forceps, the parts dried with gauze and 
cauterized with bromin. The surgeon should take a tumblerful of water 
and into it pour the bromin, which will fall to the bottom of the glass. The 
drug can be drawn up with a syringe and injected into the depths of the wound. 
The wound should be plentifully sprinkled with iodoform and dressed with 
hot antiseptic fomentations. When the sloughs separate, the sore can be treated 
as an ordinary ulcer. The constitutional treatment is that employed for sepsis. 

Special Forms of Gangrene.— Symmetrical or Raynaud ; s gangrene 
arises in severe cases of Raynaud's disease. It is a dry gangrene. Ray- 
naud's disease is a vaso-motor neurosis, seen particularly in children and young 




Fig. Si. — Raynaud's disease (Philadelphia Hospital) (Horwitz). 

female adults but sometimes met with in men. Chlorotic and hysterical 
women seem more apt than others to suffer from it. The condition is much 
commoner in winter than in summer, and cold seems to be an exciting cause. 
The essential cause of Raynaud's disease is uncertain. In some acute cases 
associated with fever, albuminuria, and splenic enlargement, it seems to be a 
part of an acute infectious disease. It can occur in a variety of toxic con- 
ditions and in a number of infectious diseases (typhoid fever, for instance). 
It may develop in the course of gout and also "of diabetes. In many cases 
neuritis exists; in some there is obliterative endarteritis of the peripheral ves- 
sels. Some cases seem to be purely hysterical. The fact that attacks of 
Raynaud's disease are sometimes accompanied by hemoglobinuria has sug- 
gested malaria as a possible cause. Raynaud's disease is characterized by 
attacks of cold, dead bloodlessness in the fingers or toes as a result of exposure 
to cold, or of emotional excitement (local syncope). In the more severe cases 
there are capillary congestion and mottled, livid swelling (local asphyxia). 



Diabetic Gangrene 177 

The patient complains of pain, tingling, numbness, coldness, and stiffness in 
the affected parts. In some few cases the skin of the face or trunk is attacked. 
Local syncope is thought to be due to vascular spasm, and local asphyxia to 
some contraction of the arterioles, with dilatation of the capillaries and 
venules. It is after local asphyxia that gangrene may appear. A chilblain is 
an area of local asphyxia. Attacks of Raynaud's disease occur again and 
again, and may never eventuate in gangrene. 

Raynaud's disease is seldom fatal and is often recovered from. 

Raynaud's gangrene is most commonly met with upon the ends of the 
fingers or the toes, but it may attack the lobes of the ears, the tip of the nose, or 
the skin of the arms or the legs. Sometimes the disease is seen upon the trunk. 
When gangrene is about to occur the local asphyxia at that point deepens, 
anesthesia becomes complete, and the part blackens and feels cold to the 
touch. The epidermis may raise into blebs at the margin of the gangrene, 
which blebs rupture and expose dry surfaces. A line of demarcation forms, and 
the necrosed area is removed as a slough. Widespread gangrene from Ray- 
naud's disease is rare; there is not often an extensive area involved — rather 
a small superficial spot. Recovery is the rule. 

Treatment oj Raynaud's Disease and 0} Raynaud's Gangrene. — If an indi- 
vidual suffers from attacks of Raynaud's disease, every effort should be made 
to improve the general health and to avoid chilling the surface of the body. 
During the attack employ gentle massage, place the extremity in warm 
water, and, if pain is severe, give morphia hypodermatically. Amyl nitrite 
is without value in this condition. When attacks of Raynaud's disease are 
so severe as to threaten gangrene, put the patient to bed, if the feet are 
attacked, elevate the legs slightly, wrap the affected extremities in cotton- wool, 
and apply warmth. If the hands are affected, wrap them in cotton-wool, ele- 
vate them slightly, and apply warmth. Massage is useful. When gangrene 
occurs, dress the part antiseptically until a line of demarcation forms, and 
then remove the dead parts by scissors, forceps, and antiseptic fomentations. 
If amputation becomes necessary, which will rarely be the case, wait for a 
line of demarcation. 

Diabetic gangrene resembles in many points senile gangrene, but the 
dead portions remain somewhat moist and putrefy. Some attribute it directly 
to the presence of sugar in the blood. Some think diabetes causes gangrene 
indirectly by rendering the tissues less resistant to infection and less capable 
than normally of repair. Many hold that it is of neurotic origin, being the 
result of nerve degeneration. Heidenhain believes that it is due to arterial 
sclerosis. That most of the victims of diabetic gangrene suffers from arterio- 
sclerosis is certain. It seems probable that the gangrene is due to infection of 
tissue predisposed to infection by the presence of sugar and weakened by 
changes in the nerves and blood-vessels. Diabetic gangrene is most usually- 
met with upon the feet and legs of elderly people, but it may arise at any age 
and may attack the genital organs, thigh, lung, buttock, eye, back, finger, or 
neck. It may affect only a single area, may attack several areas, or may be 
symmetrical. It may arise in any stage of diabetes, from the earliest to the 
latest. It may begin as a perforating ulcer. As in senile gangrene, a trivial 
injury is apt to be the exciting cause, but it may arise without any antecedent 
injury. If an injury is causative, a condition like cellulitis arises, spreads 



178 Mortification, Gangrene, or Sphacelus 

rapidly, and eventuates in gangrene. When the gangrene follows a trauma- 
tism, there are no prodromic symptoms. When it arises spontaneously in the 
skin, it is often preceded by pain of a neuralgic nature and attacks of "livid 
or violaceous discoloration of the skin, with lowered surface temperature and 
sometimes loss of sensation" (Elliot). Diabetic gangrene is often superficial, 
but may become deep if it follows an injury or ulceration. The gangrenous 
area is somewhat moist as a rule, but may be dry. The parts about are livid 
and may be covered with vesicles. It spreads slowly, but more rapidly than 
senile gangrene. There is little tendency to the formation of any line of de- 
marcation, although occasionally spontaneous healing occurs. 

Treatment. — Surgeons have become shy of amputating in such cases, but 
the experience of Kuster, of Berlin, proves conclusively that an amputation 
should be performed at once in diabetic gangrene of the leg, and should be 
done above the knee. If operation is performed below the knee, the flaps will 
become gangrenous. It has been noted that sugar will sometimes disappear 
from the urine after an amputation. Of 11 amputations by Kuster, 6 re- 
covered and 5 died; and of these 5,3 had albumin in the urine as well as sugar.* 

Heidenhain warmly advocates early high amputation, with the making 
of short flaps. When the patient dies after operation, he usually does so in 
coma. In any case after operation, treat the diabetes by means of drugs and 
diet. Codein is often of great value. If amputation is refused or if the gan- 
grene is not upon an extremity, treat the gangrenous area by hot antiseptic 
fomentations, the daily removal of portions of dead tissue, the administration 
of antidiabetic drugs, and the use of suitable articles of diet. Never fail to 
examine the urine in every surgical case, and especially in every case of gan- 
grene, for diabetes might be present when it had not been suspected. 

Operations on Diabetics. — Surgical operations upon diabetics are regarded 
as very dangerous and are employed by most surgeons only in emergencies. 
In operations upon such subjects gangrene may rise in the wound or diabetic 
coma may develop. It is important to remember that glycosuria may result 
from a surgical condition (head injury, sepsis, etc.), and this temporary dia- 
betes will be relieved by operation. I have seen it in appendicitis, and in such 
cases operation is not contraindicated, but is imperative. Llewellyn Phillips 
in a recent article ("Lancet," May 10 and 17, 1902) refers to the temporary 
glycosuria produced by injury and sepsis. He thinks that diabetes may 
directly cause cataract and balanoposthitis, but produces gangrene indirectly 
by causing nerve degeneration and arteriosclerosis. Phillips points out that 
a surgical condition and glycosuria may exist independent of and uninfluenced 
by each other, and many such cases can be operated upon, although operation 
should be avoided if there is serious disease of some important organ (the liver, 
for instance). Phillips, in the valuable article referred to, insists that the 
percentage of sugar is not a measure of the degree of danger; that albuminuria 
adds greatly to the danger; that the presence of acetone in the urine, and also 
the presence of ammonia, gives a bad prognosis. Phillips's conclusions as 
to when to operate and when to refuse operation are as follows ("Lancet," 
May 10 and 17, 1902) : An operation for malignant disease in a diabetic can be 
performed if the operation would be proper on a non-diabetic individual. 

*See the convincing article by Charles A. Powers, in Amer. Jour, of Med. Sciences, 
Nov. 11, 1892. 



Gangrene from Frost-bite 179 

Large abdominal tumors can be removed. Cosmetic operations are justifiable 
if the general health is good and there is not marked arterial disease or nerve 
degeneration. Operation is justifiable in all emergencies without regard to 
the condition of the urine. In a diabetic with a surgical malady it is often 
possible to lessen danger by preliminary treatment. Only an operation of the 
greatest urgency should be performed if over 1 gram of ammonia is excreted 
during twenty-four hours; and if aceto-acetic acid or much albumin is present, 
every case but the most urgent should be postponed and subjected to medical 
treatment. 

I would add to the conclusions of Phillips that the anesthetic is a danger 
to the kidneys irritated by the secretion of sugar, and it is desirable, when 
possible, to use local anesthesia, or, as Robt. T. Morris advises, nitrous oxid 
and oxygen ("Medical News," June 29, 1901). In one case I used spinal 
anesthesia but the patient died in coma. If sugar diminishes in the urine but 
increases in the blood the condition is one of danger. 

Gangrene from Ergotism.— Ergotism is a diseased condition resulting 
from eating bread made with rye which has been attacked by a fungus (Clavi- 
ceps purpurea). In former days it was not unusual to have epidemics of 
ergotism from time to time, but at present the disease is found in individuals 
or at most in a few of a community. Ergotism is very rare in the United 
States. It is never seen in unweaned children. The eating of bread 
made of diseased rye provokes gastro-enteritis, the evidences of which 
are abdominal pain of a crampy character, vomiting, diarrhea, and ex- 
haustion. The patient complains of formication and itching of the skin 
of the extremities; severe, cramp-like, and tingling pains in the limbs, 
and disorders of vision. The pulse becomes small and slow. In some cases 
very painful spasms attack the muscles of the extremities and finally tonic 
spasm is noted and the patient probably perishes from exhaustion after de- 
veloping general convulsions and passing into coma. In other cases certain 
areas exhibit "gradual blood-stasis" (Osier), anesthesia, and finally gangrene. 
The gangrene is dry and peripheral. It usually affects the fingers or toes, but 
may involve an entire limb, and may be symmetrical. Chronic ergotism 
is usually recovered from, but acute cases die in from seven to ten days* 
The ingestion of ergot in quantity sufficient to produce chronic poisoning 
causes tonic contraction of the peripheral blood-vessels, degeneration of the 
inner coat, and thrombosis of some arterioles. It is also maintained that 
degeneration of the posterior columns of the spinal cord takes place. 

Treatment. — Ergotism is treated by forbidding the eating of the poison- 
ous bread, allaying gastro-enteric inflammation, favoring elimination, and 
administering nourishment and stimulants. If gangrene is threatened, en- 
deavor to prevent it by gentle massage and the application of warmth. If 
superficial gangrene occurs, dress with warm antiseptic fomentations and 
elevate the part, and every day take scissors and forceps and remove the loose 
crusts. If deeper and more extensive gangrene arises in an extremity wait 
for a line of demarcation and amputate above it. 

Gangrene from Frost-bite. — Frost-bite is most common in the fingers, 
toes, nose, and ears, but the genital organs, the cheeks, the chin, the feet and 
legs, and the hands and arms may be attacked. Cold causes a primary con- 
*Pick, in Heath's "Surgical Dictionary." 



180 Mortification, Gangrene, or Sphacelus 

traction of the vessels and pallor and numbness of the part. After reaction 
the vessels dilate, the part reddens and swells, and a burning sensation or 
actual pain is experienced. In a trivial frost-bite the swelling and redness 
usually disappear after a few days, but in some cases the redness is permanent, 
and in many cases the redness, in the form of local asphyxia, returns under 
the influence of slight cold (see Chilblains). 

In a more severe frost-bite the affected part becomes purple and covered 
with vesicles, and gangrene may or may not follow. When a part has been 
badly frozen the peripheral portion dries. The part is deprived of all blood 
because of contraction of the vessels and because plasma coagulates at a few 
degrees above freezing. Cold disorganizes the blood, breaking up white 
corpuscles with the liberation of fibrin ferment. Coagulation of plasma 
and destruction of red corpuscles with the liberation of hemoglobin subse- 
quently takes place. The thrombosis which is established prevents circula- 
tion, and the tissue-cells are damaged beyond repair. The part is bloodless 
and anesthetic, and a line of demarcation forms. Hence we note that severe 
frost-bite causes dry gangrene. If a part which is not so badly frozen is 
brought suddenly into a warm atmosphere, hyperemia takes place when the 
blood runs into the frosted tissues, blebs form, and moist gangrene may result. 
Areas of superficial gangrene are not uncommon. 

Treatment of Frost-bite and 0} Gangrene from Frost-bite. — A frost-bite in 
which the skin is livid and not as yet gangrenous should be treated by frictions 
with snow or rubbing with towels soaked in iced water. As the skin becomes 
warmer and congestion disappears the part should be wrapped in cotton- 
wool. A sufferer from frost-bite should not suddenly be brought into a warm 
room. When gangrene follows frost-bite, if only small areas are involved, allow 
the dead parts to come away spontaneously, applying in the meanwhile hot 
antiseptic fomentations. If separation be delayed by cartilage, ligament, or 
bone, cut through the retaining structure. If amputation becomes necessary, 
await a line of demarcation, as it is not possible otherwise to be certain how 
high tissue damage extends, and to amputate through devitalized parts would 
mean renewed gangrene. 

Noma. — Noma is a rapidly spreading gangrenous process which is most 
apt to begin upon the mucous membrane of the gums or cheeks. Noma of 
this region is known as cancrnm oris. Occasionally it begins in the ears, the 
genitals, or the rectum. When it attacks the vulva it is called noma pudendi. 
It may originate in the mouth and subsequently attack other regions. Noma 
is a very rare disease, is chiefly met with in children between the ages of three 
and ten, but it can attack older persons. (O. Zusch, in " Munchener medicin- 
ische Wochenschrift," for May 14, 1901, reports a case in a man sixty-six 
years of age.) It occurs in girls oftener than in boys. The disease is most 
frequently encountered in children recovering from an acute disease. It is 
seen after scarlatina, typhoid, pneumonia, dysentery, and especially after 
measles; in fact, Osier says that over one-half the cases follow measles. 
Children of tuberculous tendencies seem more liable than others. Young chil- 
dren who live amid filth and squalor in damp and ill-lighted apartments are 
most prone to suffer, but that such conditions are not essential to the genesis 
of the disease is shown by the report of an epidemic of noma in the Albany 
Orphan Asylum. In this excellently situated, well-lighted, and well-ventilated 



Phagedena 181 

building the children are carefully fed and cared for, and yet 16 cases of 
noma occurred after an epidemic of measles. (See " An Epidemic of Noma," 
by Geo. Blumer and Andrew MacFarlane, in "Amer. Journal of Med. 
Sciences," Nov., 1901.) The disease is thought by many to be due to pus 
organisms. Lingard describes a bacillus which he considers causative. 
Blumer and MacFarlane conclude that the disease begins as a simple infec- 
tion and a mixed infection takes place later. The mixed infection is not al- 
wavs due to the same organism, but is usually due to a long organism of a lep- 
tothrix type ("Amer. Journal of Med. Sciences," Nov., 1901). 

Symptoms. — The disease begins as a sloughing ulcer, and thrombosis and 
gangrene soon begin. The edges of the ulcer are dark red and indurated. The 
gangrene usually spreads with very great rapidity, but in some cases it remains 
apparently stationary for days at a time. There is little or no pain. The 
odor is horrible. The disease is frightfully destructive, and if the mouth is 
involved is apt to destroy the cheeks, lips, eyelids, and large portions of the 
jaws. There is usually fever, but the temperature may be normal or even 
subnormal. The pulse is rapid and exhaustion appears early and deepens 
rapidly. The mortality is large; Bruns says 70 per cent.; Rilliet and Barthez 
say 95 per cent. ("Amer. Journal of Med. Sciences," Nov., 1901). The 
cause of death is exhaustion, pyemia, or septic bronchopneumonia. 

Treatment. — Administer an anesthetic and destroy the gangrenous area 
with the Paquelin cautery. In noma of the mouth chloroform is used instead 
of ether because the hot iron is to be applied in a region surrounded with 
anesthetic vapor and ether vapor is inflammable. In noma in some other 
region ether can be given. After cauterization directions are given to wash 
the part every few hours with peroxid of hydrogen, irrigate it with hot salt 
solution or boracic acid solution, and dress it with compresses soaked in 
Labarraque's solution (Blumer and MacFarlane, in "Amer. Journal of Med. 
Sciences," Nov., 1901). Nourishing food is given at frequent intervals, alcohol 
is administered, and strychnin is used to combat weakness. If the surgeon 
succeeds in arresting the gangrene it will probably be necessary later to per- 
form a plastic operation in order to replace loss of substance. 

Sloughing is a process by which visible portions of dead tissue are sepa- 
rated. These visible portions are called "sloughs"; if they were large, they 
would be called "gangrenous masses." A large septic slough is a gangrenous 
mass; a small gangrenous mass is a slough; there is no difference in the 
process, which corresponds to the formation of a line of demarcation. 

Treatment. — Sloughing requires thorough and frequent irrigation with 
an antiseptic fluid, removal of the sloughs, and antiseptic treatment. An 
irrigator can be improvised from an ordinary bottle (Fig. 82). Warm 
antiseptic fomentations are applied until granulation is well advanced. In 
some cases continuous irrigation with a hot antiseptic fluid is useful; in other 
cases continued immersion in a hot antiseptic solution is employed. 

Phagedena is a process of ulceration (most common in venereal sores) in 
which the surrounding tissues are rapidly eaten up, the sore becoming jagged 
and irregular, with a sloughy floor and thin edges. The discharge is thin 
and reddish, and the encircling tissues are deeply congested. This ulcer 
has no tendency to heal. Phagedena may attack wounds, but in this age is 
almost never seen except in venereal sores. When it does so the wound dis- 



182 



Mortification, Gangrene, or Sphacelus 



charge is arrested, the parts about the wound become dark red and swollen, 
a black slough forms upon the wound and the process spreads rapidly in all 
directions. The process when it attacks a wound is similar to or identical 
with a mild case of hospital gangrene, differing from the gangrene in the fact 
that in most cases a line of demarcation forms and the depres- 
sion is not so great. Phagedena is probably due to mixed 
infection with pus organisms. 

The treatment of phagedena consists in repeated touch- 
ing with tincture of chlorid of iron and the local use of iodo- 
form, the employment of continued irrigation or immersion 
in hot antiseptic fluids, or the application of the cautery, chem- 
ical or actual. After using the cautery the part is dressed with 
hot antiseptic fomentations. Whatever else is done, tonics, 
stimulants, and nutritious diet must be given and opium is 
often required. 

Decubitus, Decubital Gangrene, or Bed=sore.— A 
bed-sore is the result of local failure of nutrition in a person 
whose tissues are in a state of low vitality from age, disease, 
or injury. The arterial condition of the aged favors the de- 
velopment of bed-sores. Such sores are due to pressure, aided 
it may be by some slight injury or by the irritation produced 
by urine, feces, sweat, crumbs or other foreign bodies in the bed 
or by wrinkling of the sheets. The pressure destroys vascular 
tone, stasis results, thrombosis occurs, and gangrene follows. 
They occur over the heels, elbows, scapulae, trochanters, sac- 
rum, and nucha. In some cases, after pressure is removed 
there are stasis, vesication, suppuration, and the formation of 
an ugly ulcer, surrounded by a zone of swelling and hyper- 
emia. These ordinary pressure-sores arise like splint-sores due 
to the pressure of a splint upon the tissues over a bony promi- 
nence. The pressure interferes with the blood-supply, the 
weakened tissues inflame, vesication occurs, sloughs form, and an ugly ulcer 
is exposed. When a bed-sore is about to form, the skin becomes red and 
edematous. Pressure with the finger drives the color out rather slowly. The 
color becomes purple or black, a slough forms and separates, and a large, 
irregular, foul cavity is exposed. The discharge is profuse and offensive. 
The parts about are swollen and red. If the sore is not upon an anesthetic 
part, much suffering is produced by it. Bed-sores are most common in par- 
alyzed parts; such parts are anesthetic, and injurious pressure is not painful 
and does not attract attention, and in such parts there is vaso-motor paresis. 
The acute bed-sores of Charcot are seen during certain diseases and 
after some injuries of the nervous system. These sores are usual over the 
sacrum in acute myelitis, and may appear in four or five days after the begin- 
ning of that disease or the infliction of an injury upon the spinal cord. The 
surgeon sees acute bed-sores upon the buttock of the paralyzed side after 
brain-injuries, and over the sacrum in spinal injuries. Some believe these 
sores are due to vasomotor disorder; but others, notably Charcot, attribute 
them to disturbance of the trophic nerves or centers. 

Treatment of Bed-sores. — The "ounce of prevention" is here invalu- 



Fig. S2. — Im- 
provised appara- 
tus for the irriga- 
tion of a wound. 



Carbolic Acid Gangrene 183 

able. From time to time, if possible, alter the position of the patient, keep 
him clean, maintain the blood-distribution to the skin by frequent rubbing 
with alcohol and a towel, keep the sheet clean and smooth, and in some situa- 
tions use a ring-shaped air-cushion to keep pressure from the part. When 
congestion appears (paratrimma, or beginning sore), at once use an air-cushion 
or a water-bed and redouble the care to frequently change the position of the 
patient. Not only protect, but also harden, the skin. Wash the part twice 
daily and apply spirits of camphor or glycerol of tannin; or rub with salt and 
whiskey ( o i j to Oj) ; or apply a mixture of § ss of powdered alum, f 5 ij of tinc- 
ture of camphor, and the whites of four eggs; or paint with corrosive subli- 
mate and alcohol (gr. ij to§j); or apply tannate of lead or equal parts of oil 
of copaiba and castor oil; or paint upon the part a protective coat of flexible 
collodion. 

When the skin seems on the verge of breaking, paint it with a solution of 
nitrate of silver (gr. xxto §j). When the skin breaks, a good plan of treat- 
ment is to touch once a day with a solution of silver nitrate (gr. x to o j) and 
cover with zinc-ichthyol gelatin. We can wash the sores daily with 1 : 2000 
corrosive sublimate solution, dust with iodoform, and cover with soap plaster, 
with lint spread with zinc ointment, or with dry aseptic gauze. When sloughs 
form, cut most of them off with scissors after cleaning the parts, slit up sinuses, 
and use antiseptic fomentations. In sloughing Dupuytren employed pieces of 
lint wet with lime-juice and dusted the sore with cinchona and charcoal. In 
obstinate cases use the continuous hot bath. When the sloughs separate, 
dress antiseptically or with equal parts of resin cerate and balsam of Peru. 
If healing is slow, touch occasionally with a solution of silver nitrate (gr. x to 
5j). Bed-sores, being expressive of lowered vitality, demand that the patient 
shall be stimulated, shall be well nourished, and shall obtain sound sleep. 

Ludwig's Angina (Angina Ludovici). — This disease is a streptococcus 
infection about the submaxillary salivary gland and in the cellular tissue beneath 
the mucous membrane of the floor of the mouth and of the upper portion of 
the neck. The inflammation eventuates in suppuration and gangrene. The 
disease arises as a painful swelling in the neighborhood of the submaxillary 
gland. The swelling rapidly increases, involves the neck and floor of the 
mouth, causes great difficulty in opening the mouth and in swallowing and 
may lead to edema of the glottis.* The constitutional symptoms are those 
of septicemia or pyemia. The disease may arise in an apparently healthy 
man or during or after an infectious fever. The streptococci enter from the 
mouth by way of abrasions, wounds, ulcerations, or dental caries. It may 
be caused by delayed development of the third molar, necrosis of the tooth and 
alveolar process taking place and an abscess forming (G. G. Ross, "Annals 
of Surgery," June, 1901). 

Treatment. — At once incise below the body of the lower jaw, open the 
submaxillary space, cut away gangrenous tissue, paint the wound with pure 
carbolic acid, pack with iodoform gauze, and apply hot antiseptic fomentations. 
The constitutional treatment is that of septicemia. 

Carbolic Acid Gangrene. — Dressings moistened with a solution of 
carbolic acid of a strength of from 3 to 5 per cent, may, if wrapped for a num- 
ber of hours around a finger or toe, cause dry gangrene. There is but 
*Tillmann's " Text-Book of Surgery," translated by B. T. Tilton. 



184 Mortification, Gangrene, or Sphacelus 

little danger when such dressings are applied to the tissues of the trunk, be- 
cause these thicker tissues are better nourished and cannot be completely 
surrounded by the wet dressings. The application of strong acid rarely 
causes gangrene, but Levan found 14 reported cases in which it did (J. Levan, 
in "Centralbl. f. Chir.," August 14, 1897). The continuous application of 
a weak solution is very dangerous and ought never to be practiced. The 
author has seen 4 cases. Harrington saw 18 cases of gangrene in five years in 
the Massachusetts General Hospital, and collected 132 cases from literature 
("Boston Med. and Surg. Jour.," May 2, 1901). Carbolic acid gangrene is 
due to great exudation irtfo the cellular tissue, blocking the circulation (Hou- 
sell), and the production of arterial thrombi, a condition to which the patient 
is predisposed by the injury and often by tight bandaging. The dressing is 
frequently applied by a druggist; it produces anesthesia of the part, and the 
dressing is often not removed for days although gangrene may be progressing 
beneath. In the author's 4 cases there was no smokiness of the urine or any 
other evidence of absorption of the drug. 

Treatment. — If the gangrene is very superficial, recovery may be obtained 
by using hot fomentations and picking the dead parts gradually away. In 
most cases the finger or toe is completely destroyed, a line of demarcation 
forms, and amputation is required. 

Post=febrile Gangrene.— Dry or moist gangrene may follow any fever, 
but is most frequent after typhoid (may follow typhus, influenza, measles, 
scarlet fever, etc.). Keen tells us that the gangrene resulting from arterial 
obstruction is apt to be dry, and that from venous obstruction is usually 
moist. The same observer has collected 203 cases.* It is most usual in the 
lower extremities, but may appear in the upper extremities, cheeks, ears, nose, 
genitals, lungs, etc. Some writers have assigned as the cause weakness of 
cardiac action, but most observers believe an obstructing clot is the usual 
cause. This clot may come from the heart, but is in most cases secondary to 
endarteritis due to the action of the toxins of the bacilli of the specific fever. 
Keen shows that in some cases gangrene is due to obstruction of peripheral 
vessels and not of a main trunk. In rare cases gangrene arises after throm- 
bophlebitis. Gangrene may begin as early as the fourteenth day of the fever, 
but usually appears late in the disease and may arise far into convalescence. 
In the course of a continued fever frequent examinations should be made to 
see that gangrene is not arising. Particular examination from time to time 
should be made of the lower extremities, and in young girls, of the genitals. 
If gangrene arises in an extremity, apply antiseptic dressings, wait for a line 
of demarcation, and then amputate. If gangrene occurs in other regions, 
remove the dead tissue and employ hot antiseptic fomentations. 

Rules when to Amputate for Gangrene.— In dry gangrene, due to 
obstruction of a non-diseased artery, wait for a line of demarcation. In senile 
gangrene, if it affect only one or two toes, let the dead parts be cast off spon- 
taneously. If a greater area is involved or the process spreads, amputate 
above the knee without waiting for the line. In ordinary moist gangrene, if 
there are not severe symptoms of sepsis, and if the gangrene is not rapidly 
progressive, wait for a line of demarcation. In the severer cases amputate 
at once high up. In traumatic spreading gangrene amputate at once. In 
* Keen on the "Surgical Complications and Sequels of Typhoid Fever." 



Causes of Thrombosis 



185 



diabetic gangrene amputate at once, high up. In ergot gangrene, in carbolic 
acid gangrene, in post-febrile gangrene, in Raynaud's gangrene, and in frost 
gangrene wait for a line of demarcation. 



IX. THROMBOSIS AND EMBOLISM. 

Thrombosis is the ante-mortem coagulation of blood in the heart or in a 
vessel, the coagulum remaining at its point of origin and plugging up the 
vessel partially or completely. The process, and also the condition significant 
of the process, is known as thrombosis; the clot is called the thrombus. This 
process is an essential part in the arrest of hemorrhage; it occurs in phlebitis 
and arteritis, and affords a frequent basis for embolism. The thrombus is com- 
posed of red corpuscles, white corpuscles, fibrin, and platelets in varying pro- 
portions. Thrombi may form in the veins, in the arteries, in the capillaries, 
or in the heart. Clotting is due to destruction of white blood-cells, fibrin 
ferment being set free, causing the union of calcium and fibrinogen and 
thus forming fibrin. Thrombosis is more common in the veins than in 
the arteries, the slow blood-current and the existence of valves favor- 
ing the deposit, though not causing it. A thrombus forms gradually, being 
deposited layer by layer; hence it is stratified or laminated. Fig. 83 shows a 
thrombus in a vein. All thrombi are either infectious or simple, the latter 
being also called aseptic or bland. Thrombi are also 
spoken of as fibrinous, red, hemostatic, leukocytic, etc. 

Causes of Thrombosis. — In the formation of 
thrombi four conditions are to be considered, viz., chemi- 
cal alterations in the blood, a bacterial attack on the 
intima, tissue changes in the inner coat of the vessel, and 
slowing of the circulation. One, several, or all of these 
conditions may exist in a case of thrombosis. In arteries 
the chief causes are disease of the coats and embolism. In 
veins the chief causes are injury and infectious phlebitis. 
Capillary thrombi may be due to propagation from veins or 
arteries or may form in the capillaries. The latter condition 
is seldom seen. The essential cause of all intravascular 
thrombi is damage to the endothelial coat and in most Fig u f 

. saphenous vein (Green). 

instances the damage is effected by bacteria, hence most 
cases of thrombosis seen by the surgeon are infectious. Any condition which 
causes the blood to contain an excess of fibrin-forming elements favors throm- 
bosis, in the sense that a slight injury of the vascular endothelium will be followed 
by clot formation. Among conditions favoring thrombosis we must note 
particularly slowing of circulation, however, caused. A special predisposing 
condition is the retarded circulation in tuberculosis, influenza, and fevers, 
the blood clotting behind the vein-valves after the endothelium has been 
damaged by toxins. Among other favoring states are inflammations; 
wounds; fractures; the pressure of a bandage or of a splint; varicose veins; 
ligation of a vessel; injury of a vessel; foreign bodies in a vessel; atheroma 
in arteries; sutures in a vessel; certain diseases, such as gout, typhoid fever, 
pregnancy, and septic processes; phlebitis or arteritis arising in the vessel or 




1 86 Thrombosis and Embolism 

from extension of surrounding inflammation; and the entrance of specific 
organisms. 

It has been asserted that so long as the endothelium of a vessel is unin- 
jured a clot does not form. Slowing of the blood-current in aseptic conditions, 
it is now taught, will not cause thrombosis. One of the functions of the endo- 
thelial coat is to keep the blood fluid by preventing corpuscular disintegration. 
A thrombus can form only when fibrin ferment is set free, and fibrin ferment 
can be set free only when white corpuscles disintegrate. When moving blood 
coagulates, the third corpuscles or platelets first settle out and form a nucleus 
and then the leukocytes gather about it. This is known as the white or "ante- 
mortem" thrombus — the clot of moving blood. Thrombi from moving blood 
are rarely pure white; they contain some red corpuscles, forming mixed 
thrombi. White thrombi and mixed thrombi are stratified and are at first 
soft but harden as they age. The red thrombus plugs vessels which are cut 
across or ligated; it also occurs in septic processes and is formed after death. 
A primary thrombus remains in the original region of thrombosis. A secondary 
tJirombus forms about an embolism. A propagating or spreading thrombus 
extends a considerable distance from the seat of initial disturbance. A throm- 
bus soon undergoes a change. An aseptic clot usually "organizes" — that is, 
the clot is absorbed and is replaced by fibrous tissue. The walls of the injured 
vessel become filled with leukocytes, leukocytes invade the clot, the vascular 
endothelium proliferates, and the young cells follow the colonies of leukocvtes 
into the thrombus. The thrombus is gradually removed by leukocytes and 
replaced by fibroblasts, the new tissue is vascularized and becomes granula- 
tion tissue, the granulation tissue is converted into fibrous tissue, and the 
fibrous tissue contracts. In some instances a thrombus is implanted on the 
wall of the vessel, and the tube is not permanently occluded. Such a con- 
dition may be obtained by the application of a lateral ligature about a small 
tear in a large vein. In most instances, after the formation of an intravascular 
thrombus, the vessel is converted into a narrow cord 
of fibrous tissue. A thrombus may degenerate and 
break down (fatty degeneration), giving rise to em- 
boli or undergoing calcification. A calcified throm- 
bus in a vein is known as a phlebolith. An infected 
thrombus may undergo liquefaction, infective emboli 
being set free (Fig. 84). 

A clot may propagate in both directions, that is, 
toward the periphery and toward the center. It 
was taught for many years that when an artery is 
ligated a thrombus quickly forms and reaches to the 

Fig. S 4 .-Infected thrombus ° 1 u rr U - ■ , 

of a vein (schematic). h rst collateral branch above. Ihis view was formu- 
lated in preantiseptic days. It is now known that 
when aseptic ligation is performed the thrombus is small and rarely reaches 
the first collateral branch; and is often actually absent, vascular obliteration 
being obtained by proliferation of connective-tissue cells and of cells from the 
endothelial coat. If any infection takes place the clot will reach the first col- 
lateral branch. The old rule of surgery was as follows: If an artery is cut 
near a large branch, tie the branch as well as the artery, in order to permit of 
the formation of a lengthy clot. This rule is no longer followed unless infec- 
tion exists or is anticipated. 




General Symptoms of Thrombosis 187 

A clot in a vein often extends a long distance. The author has seen in a 
post-mortem examination a venous thrombus reaching from the ankle to the 
vena cava. A common example of thrombus in a vein is the clot formed in the 
uterine sinuses in a condition of puerperal sepsis, a clot which tends to extend 
into the iliac and femoral veins. In infectious thrombosis of the lateral sinus, 
thrombophlebitis arises and the clot tends to extend up to the torcular and 
into other sinuses and down into the jugular. Phlegmasia a/ha dolens or 
milk leg is a condition in which the leg or the leg and thigh are swollen 
and painful because of venous thrombosis or sometimes lymphatic throm- 
bosis. 

Lymphatic Thrombosis. — Occasionally occurs in the thoracic duct, axillary 
lymphatics, or inguinal lymphatics. It is most common in the uterine lymphat- 
ics during puerperal fever. Lymphatic thrombosis may be due to infection, 
to cancer, to tuberculosis, or to change in the lymph itself. 

General Symptoms. — The symptoms are dependent on the seat of the 
obstruction and the presence or absence of infection. An organ or a 
part of an organ may exhibit functional aberration. The local signs in 
a vessel accessible to touch or sight are the presence of a clot; if it be 
in an artery, anemia and the absence of pulse below the clot; if it be a 
vein, swelling and edema below it. There is usually pain at the seat of 
trouble, and anesthesia below it. Moist gangrene may follow venous throm- 
bosis, and dry gangrene, arterial thrombosis. Thrombosis of the mesen- 
teric vein is followed by gangrene of the bowel. Infective thrombophleb- 
itis is a spreading inflammation of a vein. A septic thrombus forms and the 
condition is an early step in pyemia. We see this condition sometimes in 
the lateral sinus of the brain as a result of suppuration in the middle ear; in 
any of the cerebral sinuses after infected compound fracture of the skull; and 
in the uterine veins in puerperal sepsis. Thrombo-arteritis is a spreading 
inflammation of an artery in which a septic thrombus forms or in which a 
septic embolus lodges. It occasionally attacks an aneurysmal sac. In in- 
fectious thrombophlebitis and in arterial pyemia the symptoms are, of course, 
those of pyemia. A great danger of thrombosis is embolism, especially pul- 
monary embolism. 

Infectious Thrombosis of the Lateral Sinus. — (See page 720.) 

Thrombosis oj the Jugular Vein. — This condition is usually infectious and 
secondary to infectious thrombosis of the lateral sinus or sometimes of the 
petrosal sinus. It is occasionally due to cancer, tuberculosis, acute rheu- 
matism, or pyemia taking origin from a distant focus. If it. is infectious, 
the chills, the high and fluctuating temperature, and the great exhaustion 
proclaim the existence of pyemia. Locally the vein feels hard, the adjacent 
tissues are edematous, the branches of the jugular are visibly distended, 
there may be linear discoloration over the course of the jugular, and the head 
is held stiffly with an inclination to the diseased side. 

Thrombosis of the Mesenteric Vessels. — The arteries are affected much 
more commonly than the veins and the superior mesenteric artery far more 
often than the inferior. Vascular disease is the cause of arterial thrombosis 
and arterial thrombosis occurs chiefly in those beyond middle life. Venous 
thrombosis may be primary and has been observed after splenectomy, the 
clot having propagated to the mesenteric veins. It may occur as a result of 



1 88 Thrombosis and Embolism 

any gastrointestinal or general infection (pyemia, appendicitis, typhoid fever). 
Secondary venous thrombosis is due to portal obstruction or accompanies 
arterial mesenteric thrombosis. 

Mesenteric thrombosis usually produces sooner or later gangrene of the 
gut, but does not always do so. 

The period at which gangrene develops after blocking is uncertain; it 
may arise in thirty-six hours, it may not arise for two weeks or more. The gut 
becomes distended, bloody serum exudes into the peritoneal cavity, and in 
most cases into the lumen of the bowel. The mucous membrane undergoes 
necrosis and perforation occurs. The area involved varies greatly in differ- 
ent cases. In some cases it is very limited, and is rather apt to be in the large 
intestine. In other cases it is very extensive, and is apt to be in the small 
intestine. In a case of the author's in the Jefferson College Hospital prac- 
tically the entire ileum was gangrenous and numerous perforations existed. 

In mesenteric thrombosis pain arises rather suddenly and rapidly becomes 
severe. It is a persistent pain with paroxysmal exacerbations and is usually 
generalized, though in many cases it has an area of peculiar intensity. The 
pain is accompanied by rapid pulse, growing exhaustion, distention, subnormal 
temperature, tenderness, a mass appreciable by palpation in the region of the 
mesentery, free fluid in the peritoneal cavity, nausea, and vomiting. The 
condition suggests intestinal obstruction. The vomited matter consists first 
of the contents of the stomach, then of bile, finally becomes stercoraceous, 
and sometimes contains blood. 

In nearly one-half of all cases blood in considerable quantity passes from 
the rectum. 

Ballance points out that cardiac disease or arterial degeneration suggests 
the artery as the seat of thrombosis. 

The only chance for recovery without operation is the establishment of 
the collateral circulation, and as the superior mesenteric vessels are terminal 
vessels this seldom occurs (in only about 5 per cent, of cases). 

Thrombosis after Abdominal Operations. — This complication is occasionally 
encountered and is most often met with in the left side, even when the opera- 
tion was in the middle line or the right side. It is a rare complication, occur- 
ring, according to Professor Clark, 35 times in a series of 3000 operations. 

Many explanations have been given of it. A great many surgeons regard it 
as infectious, but many cases certainly are not. Clark believes it is due to injury 
of the deep epigastric vein, forcible and prolonged separation of the wound 
edges by retractors being a common cause. The free anastomosis between 
the epigastric veins of the two sides accounts for the appearance of thrombosis 
on one side after operation on the other. It probably in many slight cases is 
not recognized and it will not be recognized unless the clot reaches the femoral 
vein, and it requires one or two weeks to reach this vein if it does so at all. 
When a clot forms in the femoral vein a milk leg develops. The entire ex- 
tremity swells below the seat of thrombus, the temperature is usually normal 
but may be slightly elevated. 

Thrombosis in General Infections. — In typhoid fever a thrombus may 
form in the heart, the veins or the arteries. Thrombosis may occur in pneu- 
monia, in influenza and in other fevers, and in tuberculosis. The vessels of 
a limb, a lung, the brain or the mesenteric zone may suffer. The condition 



Embolism 



189 



follows bacterial infection, the veins are most prone to suffer and gangrene 
may ensue. 

Thrombosis in Appendicitis. — In about 2 per cent, of cases, according to 
Sonnenberg, this complication is noted. It may affect the femoral or saphenous 
vein of either side or of both sides, the portal vein or the vena cava, and may 
occur during an acute attack but is more often noted in an interval. 

It is not very unusual to find a liver abscess follow appendicitis, the in- 
fection being carried by the portal vein and the condition being known as 
septic pylephlebitis (page 878). 

Treatment. — If an aseptic thrombus forms in a large vessel of a limb, raise 
the limb a few inches from the bed, keep it perfectly quiet to avoid detachment 
of fragments (emboli), apply a bandage lightly from the toes up, and place 
warm bottles around the extremity. Maintain rest for four or five weeks. The 
great danger is the formation of emboli, hence movements and rough handling 
are to be avoided. Gangrene is another danger, hence it is wise to favor venous 
return and the development of the collateral circulation by warmth, elevation, 
and bandaging. In infectious thrombophlebitis, if the vessel is accessible, tie 
it above and below the clot, open the vessel, remove, irrigate, and pack the 
wound with iodoform gauze. The general 
treatment for a septic condition should be stimu- 
lating and supporting. Massage is unsafe in 
any condition of thrombosis, and is particularly 
dangerous in septic thrombosis. In thrombo- 
arteritis treat as in the thrombo-phlebitis. If 
gangrene of an extremity follows thrombosis 
treat as previously directed (page 169). Gan- 
grene of the intestine in mesenteric thrombosis 
if not too extensive is treated by resection. 

The treatment of infectious thrombosis of 
the lateral sinus is set forth on page 721. 

Embolism signifies vascular plugging by a 
foreign body (usually a blood-clot) which has been brought from a distance. 
The foreign body is called an embolus. An embolus usually consists of a sepa- 
rated or ruptured portion of a thrombus, atheromatous material from a dis- 
eased artery, or a bit of fibrin from a diseased heart valve. In some cases an 
embolus consists of bacteria, or air, or fat, of a fragment of a tumor, or of 
parasites. In severe burns the blood undergoes changes and jelly-like matter 
is often precipitated and may cause embolism. Emboli vary in shape, in 
size, and in consistency. Emboli are divided into simple, bland or aseptic 
and injections, toxic or septic. Emboli may arise either in the venous or in 
the arterial system, but are particularly prone to arise in the veins; they lodge 
in an artery, in capillaries, or in the veins of the liver. An embolus taking 
origin in one of the systemic veins passes through the right heart and lodges in 
a terminal branch of the pulmonary artery. If at this point it disintegrates, 
smaller emboli pass to the left heart and enter the arterial circulation to 
be deposited, as are emboli originating in the heart or arteries, in the arteries 
of an extremity, the kidneys, spleen, or brain. Emboli of the portal circulation 
lodge in the liver or perhaps pass through that organ and reach the lungs. 
An embolus is arrested when it reaches a vessel whose diameter is less 




Fig. 85.— Embolus impacted at bi- 
furcation of a branch of the pulmon- 
ary artery (Green}. 



190 



Thrombosis and Embolism 



than its own. It is usually caught just above a bifurcation. When an 
embolus lodges, it at once partially or entirely obstructs the circulation, and 
increases in size by thrombosis. Fig. 85 shows an impacted embolus. A non- 
septic embolus when lodged usually "organizes," as does a thrombus, and, as 
described on page 1 22, is replaced ultimately by fibrous tissue. A soft embolus 
may disintegrate and permit the re-establishment of the circulation. An em- 
bolus may cause an aneurysm. A septic embolus breaks down, forms a 
metastatic abscess, and sends other emboli onward in the blood-stream. 

An embolus is more serious than a thrombus: it causes sudden plug- 
ging, which makes dangerous anemia inevitable, and it will produce 
gangrene if the collateral circulation fails. Embolism of the mesen- 
teric artery causes necrosis of the intestine. In organs with terminal arteries 
(spleen, kidney, brain, and lung) there is no collateral circulation and embol- 
ism causes infarction. For instance, if an embolus lodges in the lung it pro- 
duces an area of anemia; the removal of all propulsion upon the venous blood 

causes it to flow back and stagnate, and vas- 
cular elements exude, forming a wedge- 
shaped area of red tissue, the embolus being 
the apex of the wedge. This is known as 
hemorrhagic or red infarction, and is often 
seen in the lung (Fig. 86). The white infarc- 
tion, seen in the brain and kidney, is not due 
to retrogression of venous blood, but is due to 
anemia and resulting coagulation-necrosis. 
A septic embolus causes septic thrombosis 
and a septic infarction, and a septic in- 
farction is followed by suppuration and the 
production of a pyemic abscess. That 
emboli of the systemic venous circulation 
usually lodge in the lungs explains the occur- 
rence of pulmonary embolism after certain 
operations upon and during certain diseases 
of the regions drained by the systemic veins. 
Emboli formed in vessels of the systemic circulation lodge most often in the 
lungs, brain, kidney, or spleen. It is because emboli which pass into the portal 
vein lodge in the liver that operations upon the rectum may be followed by 
hepatic embolism and abscess of the liver. 

General Symptoms. — The symptoms depend upon the organ involved 
and the presence or absence of infection. They are sudden in onset, and 
are due to loss of function, which may be permanent or which may be fol- 
lowed by inflammation, softening, or gangrene. In a septic embolus there 
are symptoms of infection and abscess forms at the seat of lodgment. In 
the course of pyemia a chill usually means the occurrence of embolism. 
Embolism of the cerebral arteries may cause aphasia, paralysis, or coma. Em- 
bolism of the pulmonary artery may cause almost instant death. Embolism of 
a large artery of a limb produces symptoms identical with thrombus, except 
more sudden and decided. Below the obstruction the pulse is absent and 
the limb is swollen with edema, is cold, and is discolored. There is pain at 
the seat of obstruction. This condition is frequently followed by gangrene. 




a V 

Fig. 86. — Diagram of a hemorrhagic 
infarct : a. Artery obliterated by an 
embolus (e) ; v, vein filled with a 
secondary thrombus (tk) ; /, center of 
infarct, which is becoming disinte- 
grated ; 2, area of extravasation ; j, 
area of collateral hyperemia (O. 
Weber). 



Fat-embolism 191 

Embolism of the superior mesenteric artery produces symptoms similar to 
those caused by acute intestinal obstruction, and results in gangrene of a por- 
tion of the intestine. 

Pulmonary Embolism. — This condition occasionally follows operations 
and injuries and sometimes develops during certain diseases. I have seen a case 
after an operation for appendicitis, a case after an operation for varicocele, 
and a case in a man with a large lumbar contusion to which massage was in- 
judiciously applied. It is not very common. Albanus (" Beitrage klin. Chir.," 
xl) in 1 140 abdominal operations found 23 cases. The emboli may be aseptic 
or septic. The condition is most common as a result of thrombosis of the 
veins of the lower extremities, appendicitis, and strangulated hernia. Cer- 
tain post -operative pneumonias are embolic. Very small aseptic emboli 
may cause no symptoms or slight symptoms. When aseptic hemorrhagic 
infarction occurs there are symptoms. These symptoms are a chill or a 
crawl, moderate fever which may be transitory, dyspnea, rapid pulse, pain in 
the chest, sometimes rapidly advancing signs of consolidation, often a pleural 
friction sound, and bloody expectoration. Sometimes immediate death occurs. 
The mortality is always large (80 per cent.). 

A septic embolism causes metastatic abscess and usually suppurating 
pleuritis, the condition being known as septic embolic pneumonia. Recovery 
is rare but occasionally occurs. The symptoms are those of pyemia with the 
phvsical signs of consolidation and of pleuritis. 

Embolism of the Mesenteric Arteries. — The superior mesenteric is 
the vessel usually affected. It may arise in pyemia, septicemia, arterial or 
cardiac disease. The symptoms are practically identical with thrombosis of 
the mesenteric vessels (page 187). 

Treatment. — The treatment of aseptic embolism depends upon the part 
involved. In a limb, keep the part warm in order to stimulate the collateral 
circulation, elevate the extremity several inches from the bed, apply a bandage 
lightly from the periphery, and insist on perfect quiet. Massage is unsafe. 
If gangrene ensues, await a line of demarcation and amputate. In septic 
embolic arteritis in an accessible region it would be good surgery to act as 
in septic thrombophlebitis. After an operation upon veins (as the operation 
for varicocele, for varix of the leg, or for hemorrhoids), after any cutting 
operation, and after the infliction of a fracture, avoid as much as possible, 
and for some time, movements or handling, as fragments of thrombus may 
be detached. 

In mesenteric embolism exploratory laparotomy may disclose a perfora- 
tion which can be closed or a portion of gangrenous gut which can be resected. 

In aseptic pulmonary embolism enforce absolute rest, give strychnin and 
morphia hypodermatically, and inhalations of oxygen. 

In septic embolic pneumonia, pursue the same plan of treatment, unless 
a large pulmonary abscess forms or an empyema arise. In either case operate. 

Fat=embolism in the human being was first thoroughly described by 
von Recklinghausen in 1884. Magendie years before developed it experi- 
mentally in animals (Frazier). It is a process which leads to an accumulation 
in the capillaries of liquid fat after injuries of adipose tissue, high tension hav- 
ing forced the fat into the open mouths of veins. Some little fat may get into 
the blood by means of the lymphatics. Fat-embolism occasionally arises dur- 



192 



Thrombosis and Embolism 



ing osteomyelitis, after extensive bruises, crushes, or lacerations, and after 
amputations, fractures, resections, or rupture of the liver.* In a case of mine 
it developed as a result of manipulation of a fracture of the neck of the femur. 
In another case it followed amputation of the breast for cancer. This fluid fat 
accumulates especially in the capillaries of the lungs and brain. It may plug 
systemic capillaries. If the patient recovers, he does so because the fat has been 
forced through the vessels; if he dies, the death results from mechanical hin- 
drance to function and nutrition. Normal blood contains a small amount of 
finely emulsified fat (from 1 to 3 parts per 1000). In a number of physiological 
and pathological conditions the circulating blood contains considerable free 
fat. It may be found in a pregnant woman, a nursing baby, a fat individual, 
or in anyone during digestion. "It has been noted in the following condi- 
tions: chronic alcoholism; diabetes mellitus; certain diseases of the liver, heart, 
and pancreas; chronic nephritis ; splenitis; tuberculosis; malarial fever, typhus 
fever, Asiatic cholera; and poisoning by phosphorus and by carbon monoxid. 
Lipemia commonly occurs as the result of lacerated wounds of the blood- 
vessels situated in fatty tissue, and after fractures of long bones involving in- 
jury of the fatty matter" ("Clinical Hematology," by John C. DaCosta, Jr.). 

In many cases of fracture in adults 
fat is found in the urine. I have had 
this demonstrated by repeated ob- 
servations. When we recall how 
rarely simple fracture causes death 
it becomes evident that a moderate 
amount of fat in the blood is not 
dangerous or only becomes danger- 
ous if it fails to flow out. In lipe- 
mia fatty embolism may occur if the 
amount of fat becomes excessive or 

Fig. 87.— Fat-embolism of the lung after fracture if vascular damage favors plugging. 
The fat-globules and masse s, stained Symptoms. — The symptoms 

are those of edema of the lungs and 
exhaustion, often with coma or de- 
lirium, and sometimes, in the beginning, are wrongly thought to be -due to 
shock. There are restlessness, dyspnea, rapid pulse and respiration, normal 
or subnormal temperature, and pallor followed by cyanosis. The chest ex- 
hibits many coarse rales, but on percussion gives a clear note. If pulmonary 
edema becomes marked, the patient spits up a bloody froth. If life is pro- 
longed a day or two, oil is found in the urine. Small amounts of oil may be 
found in the urine after serious injuries or operations when no symptoms of 
embolism exist. For instance, for two or three days after a fracture it is often 
present. Nevertheless, the presence of the oil is always a cause of anxiety, 
and is often a warning. It is maintained by Groube that the amount of fat in 
the urine is in inverse ratio to the amount in the blood; the greater the amount 
excreted in the urine, the less the amount retained in the blood. Hence, fat in 
the urine makes the surgeon anxious, and a sudden diminution of the amount 
in the urine is a sign of grave danger if there develops increasing difficulty in 
respiration ("Rev. de Chir.," July, 1895). The inverse ratio said to be main- 
*G. H. Makins, in Heath's Dictionary. 




of the femur. 

black with osmic acid, lie in the capillaries of the 

lung. X 150. (Hektoen.) 



Air-embolism 193 

tained between fat in the blood and fat in the urine, if it really exists, is similar 
to a finding of Lepine in diabetes, that is, if a diabetic is given diuretics, the 
sugar in the urine increases and the sugar in the blood decreases. The 
symptoms of fat-embolism never occur until at least twelve hours after an 
accident, and rarely before the third day. The symptoms occur at a later 
period than those of shock, and at an earlier period than those of ordinary em- 
bolism of the lung. If some of the oil is forced through the vessels of the lung, 
it will lodge in other regions and produce other symptoms. Oil may appear 
in the urine as above stated. Urinary suppression may occur. Delirium 
may arise, there may be twitching, convulsions, or paralysis, or the patient 
may pass into coma. Severe cases of fat embolism are commonly fatal; 
milder cases are often recovered from. I have lost a case operated upon for 
carcinoma of the breast and also a case of fracture of the femoral neck from 
this cause. 

Treatment. — The treatment consists in absolute rest of the diseased or 
injured part and the administration of stimulants, such as strychnin, alcohol, 
and carbonate of ammonium, the use of external heat; the employment of 
oxygen by inhalation; and the administration of diuretics and of nitroglycerin 
hypodermatically. Artificial respiration may tide a patient over a crisis. 
If an external wound exists, free drainage must be established, and the diseased 
or damaged part should be thoroughly immobilized if possible. In order to 
prevent fat-embolism after a severe injury insist on rest. Massage used early 
after some injuries is dangerous, as it may force fluid fat into the vessels. 
When severe contusion causes the formation of a large cavity filled with blood, 
Groube wisely advises incision, to lessen the danger of fat-embolism.* 

Air=embolism. — Air may enter a vein during a surgical operation or it 
may be injected accidentally while giving a hypodermatic injection, hypo- 
dermoclysis, or a saline infusion into a vein. It may follow irrigation of the 
pleura with hydrogen peroxid (Janeway). In caisson disease it is taught by 
some that nitrogen is set free in the blood. It may occur when a cerebral 
sinus is opened, or in the uterine veins, if the uterus does not remain contracted 
after delivery. It is very seldom that any symptoms follow. It was long 
thought that such an accident must be extremely dangerous. The experi- 
ments of my colleague, Professor Hare, indicate that quantities of air may be 
injected into the veins of a dog without apparent harm. The entry of a small 
amount of air into the veins of a human being will not be apt to induce dan- 
gerous symptoms, but it may be fatal. The more rapidly it is introduced and 
the greater the amount, the greater is the danger. The manner in which it 
can induce death is doubtful. Some maintain that it causes the blood in the 
right side of the heart to froth, and thus prevents normal action of the valves, 
the heart becoming unable to propel blood through the lungs. Others main- 
tain that air reaches the cerebral capillaries and so causes cerebral anemia. 
Some believe cardiac failure results from air in the pulmonary capillaries. 
The first view is the most probable. If a surgeon divides a large vein, air 
may be sucked in, and there is particular danger in such an accident if a vein 
at the root of the neck or a cerebral sinus is torn or incised, or if the damaged 
vessel lies in scar tissue and cannot collapse. 

Symptoms. — When during an operation air enters a large vein 

* Rev. de Chir., July, 1895. 
13 



194 Thrombosis and Embolism 

there is a sucking sound, air bubbles may be noted in the wound, 
and serious symptoms may or may not follow. Twice I have wounded 
the subclavian vein and have heard this sound, but no alarming symptoms 
developed. If serious symptoms are produced, they arise suddenly, and consist 
of extreme failure of circulation, a curious whirring or churning sound on 
cardiac systole audible even without a stetoscope, deadly pallor or cyanosis, 
gasping for air, convulsions, and possibly death. 

Treatment. — Compress the vein with the finger and clamp it quickly. 
Suspend the anesthetic, lower the head, employ artificial respiration and in- 
halation of oxygen, and give strychnin hypodermatically. 



Sapremia 195 



X. SEPTICEMIA AND PYEMIA. 

Septicemia, or sepsis, is a febrile malady due to the introduction into 
the blood of pyogenic organisms or the products of pyogenic organisms or of 
saprophytic bacteria. There is no one special causative organism, and any 
microbe which produces inflammatory and febrile products may cause it. 
Either streptococci or staphylococci may be present. Pneumococci are a 
not very unusual cause. Septicemia arises by absorption of septic matter 
by the lymphatics. Clinically we distinguish two forms of septicemia: (i) 
sapremia, septic or putrid intoxication; and (2) septic infection, true or pro- 
gressive septicemia. In these conditions the area of infection is usually dis- 
covered by the surgeon; but when it cannot be located, the disease is called by 
the Germans cryptogenetic septicemia. 

Sapremia, Septic or Putrid Intoxication. — This condition is due to the 
absorption of poisonous ptoma'ins from a putrefying area. The bacteria 
do not enter the blood, but their toxins do, and, as these toxins are active 
poisons, the condition is comparable to poisoning by successive alkaloidal 
injections, the symptoms and prognosis depending upon the dose. Not 
unusually there is absorption not only of the toxins of saprophytic bacteria, 
but also the toxins of pyogenic micro-organisms. Even if some of the bacte- 
ria enter the blood, they do not multiply in this fluid. Slight symptoms 
and recovery follow a small dose; grave symptoms and death follow a large 
one. The poison does not multiply in the blood, and a drop of the blood of 
a person laboring under putrid intoxication will not produce the disease when 
introduced into the blood of a well person; in other words, the disease is not 
infective. Considerable putrid material must be absorbed to cause sapremia. 
What is known as surgical fever is due to the absorption of a small amount 
of putrid or fermented wound fluid, and is in reality a mild form of sapremia. 
If sapremia arises, it does so soon after the infliction of a wound, and after a 
large rather than small wound, when a considerable amount of wound fluid is 
pent up under pressure. It may follow labor where putrid fluid is retained in 
the womb, may follow an injury of or an operation upon a joint, mav follow 
amputation where decomposing blood-clot or wound fluid is pent up within 
the flaps, or may ensue upon an abdominal operation or injury. In sapremia 
there always exist a considerable absorbing surface and a large amount of 
dead matter which has become putrid. Roswell Park * points out that 
sapremia arises from putrefaction of a blood-clot or wound fluids which are 
retained like foreign bodies in the tissues, and does not arise from putrefaction 
of the tissues themselves. He speaks of the condition as due to the absorption 
of poison from a il putrid suppository." Sapremia will not occur after granu- 
lations form. The term putrefaction is used because this is the usual change, 
but any fermentative organism may cause the disorder. Sapremia is a malig- 
nant form of surgical fever, and its existence means an ill-drained wound, and 
a fermenting and probably putrid collection of blood-clot or wound fluid. 

In sapremia there is congestion of the stomach, intestines, and other 
abdominal viscera, particularly the kidneys, and also of the brain, and numbers 
of red blood-cells disintegrate. 

* " Treatise on Surgery by American Authors." 



196 Septicemia and Pyemia 

Symptoms. — The patient often seems to react incompletely from the 
injury; he feels miserable, complains of -headache, nausea, and pain in the 
back and limbs; or, he may react and in a day or two develop this condition 
of malaise. In some cases an aseptic fever is directly succeeded by sapremia. 
In most cases of sapremia, between twenty-four hours and two or three days 
after labor, after an injury, or after an operation, there is a chill, or at least a 
chilly sensation, though in some cases this is wanting. The temperature 
rapidly rises to 103 F. or even more. There are severe headache, dry and 
coated tongue, rapid and weak pulse, nausea, and often vomiting, diarrhea, 
great prostration, restlessness, muscular twitching, and active delirium. The 
wound is found to be foul, and commonly there is drying up of wound discharge. 
There is diminution or suppression of urine, and a strong tendency to conges- 
tion of various organs. Jaundice is not unusual. Petechial spots are frequently 
noticed upon the skin. They occur also upon mucous membranes and serous 
surfaces, and result from the plugging of small vessels with detritus of broken- 
down red corpuscles and consequent vascular rupture. Great elevation of 
temperature often precedes death. In some cases the dose of poison is 
so large that the patient passes into rapid collapse without preliminary fever. 
Some cases recover if the initial dose is not overwhelming and if additional 
doses are not absorbed. Many cases die of exhaustion. Some become 
linked with fatal pyemia or septicemia. Hemoglobin and red blood-corpus- 
cles are rapidly and notably diminished. Distinct leukocytosis exists, except 
in those cases in which the organism is overwhelmed with the poison and 
is unable to react. Cover-glass preparations do not show organisms, and 
cultures from the blood are sterile. 

Treatment. — The treatment consists in at once draining and asepticizing 
the putrid area and administering very large doses of alcohol and large me- 
dicinal doses of strychnin and digitalis. The patient should be purged and 
diaphoresis favored. The hot bath is valuable to cause sweating. The 
action of the kidneys must be maintained if possible. Purgatives, diuretics, 
and diaphoretics are given to aid in removing the toxin, and stimulants are 
used to sustain the strength of the patient during the elimination of the poison. 
Vomiting is allayed by champagne, cracked ice, calomel, cocain, or carbolic 
acid with bismuth. Food should be administered every three hours. The 
patient is fed on milk, milk and lime-water, liquid beef-peptonoids, beef- 
juice, and other concentrated foods. Quinin in stimulant doses is of value. 
Antipyretics are useless. The use of saline fluid by hypodermoclysis or intra- 
venous infusion dilutes the poison and stimulates the heart, skin, and kidneys 
to activity. Visceral complications must be watched for and should be 
promptly treated if discovered. Among the possible visceral complications 
are nephritis, cholecystitis, enteritis, hepatitis, peritonitis, pleuritis, empyema, 
bronchopneumonia, pericarditis, and endocarditis. Antistreptococcic serum 
is useless in sapremia. 

Septic Infection, or True Septicemia. — This condition is a tr.ue infective 
process. In sapremia the blood contains toxins of putrefactive bacteria, 
but not the bacteria themselves. In septic infection the blood contains 
both pyogenic toxins and multiplying pyogenic bacteria, the bacteria 
perhaps being free in the blood or in white cells. In sapremia the causative 
condition is putrid material lodged like a foreign body in the tissues. In 



Septic Infection, or True Septicemia 197 

septic infection the tissues themselves are suppurating, and both bacteria 
and toxins are being absorbed by the lymphatics. Of course, septic infection 
may be associated with septic intoxication or may follow it. In suppurative 
fever the tissues suppurate, but only the pyogenic toxins are absorbed, and 
not the pyogenic bacteria. In septic infection both the pyogenic bacteria 
and toxins enter the blood, and the bacteria multiply in the blood and pro- 
duce continually increasing amounts of poison. The symptoms of sapremia 
depend on the dose. In septic infection only a small number of organisms 
may get into the blood, but they multiply enormously. The pus microbes 
cause true septicemia, and reach the blood chiefly through the lymphatics, 
but to some degree by penetrating the walls of vessels. A drop of blood from 
a man with septic infection will reproduce the disease when injected into the 
blood of an animal; hence the disease is truly infective. The wound in such 
cases is often small, but may be large, and is commonly punctured or lacer- 
ated, and the disease begins later after the infliction of a wound than does 
sapremia. No wound may be discoverable, the infection having arisen from 
an unrecognized focus of suppuration — for instance, gonorrhea, middle-ear 
disease, dental caries, tonsillar suppuration, appendicitis, etc. Septicemia 
in which the initial atrium of infection is not discovered is called cryptogenetic 
septicemia. 

The bacteria which exist in the blood and organs in septicemia are usually 
staphylococci or streptococci, often both. Pneumococci or colon bacilli in some 
cases are causative. The blood is found to have lost much of its coagulating 
power; it remains fluid for some time after death, quantities of red corpuscles 
are destroyed, and minute hemorrhages take place in the brain, mucous mem- 
branes, skin, serous membranes, muscles, and various viscera. There may 
be inflammation of synovial and serous membranes. There is congestion of 
the gastro-intestinal tube and of the abdominal viscera. The lymph-glands 
are larger than normal and the spleen is notably enlarged. The wound con- 
tains numbers of bacteria. 

Symptoms. — The type of this condition is met with in puerperal septicemia 
or in septicemia from an infected wound. When septicemia arises from an 
infected wound, red lines due to lymphangitis are usually seen about the 
wound, and there is enlargement of related lymphatic glands. In some cases, 
however, the wound and the parts about.it look normal. A supposed aseptic 
fever after an injury may continue for an undue time and the surgeon may 
find that septicemia has developed. Septicemia may arise during the exis- 
tence or after the abatement of sapremia, or may arise when the aseptic fever 
has passed away and when there has been no putrid intoxication. It begins 
in from four to seven days after labor or an injury, usually with a chill, which 
is followed by fever, at first moderate, but soon becoming high. In some 
cases there is a chilly sensation, but no distinct chill. There is always great 
prostration even before the chill. The fever presents morning remissions and 
evening exacerbations, and may occasionally show an intermission. When 
the remission begins there is a copious sweat. As the case progresses the 
temperature may fluctuate, and it often rises very high before death. The 
pulse is small, weak, very frequent, and compressible. The tongue is dry 
and brown, with a red tip. Sordes gather on the teeth and gums. Vomiting 
is frequent, and, as a rule, there is diarrhea. Low delirium alternates with 



T98 Septicemia and Pyemia 

stupor, and coma is usual before death. The great prostration is a noticeable 
and characteristic feature of the sufferer from septicemia. There are sub- 
sultus tendinum (twitching of the muscles of the hands and feet) and carpho- 
logia (picking at the bedclothing). Toward the end the face often becomes 
Hippocratic (hollow temples, pinched nose, sunken eyes, livid skin, lead-colored 
and cold ears, and relaxed lips). Visceral congestions occur. The spleen is 
enlarged, ecchymoses and petechia? are noted, urinary secretion becomes scanty 
or is suppressed, and the wound becomes dry and brown. Blood-examination 
detects a rapid and great diminution in red corpuscles and hemoglobin. The 
anemia is in many cases profound. There is marked leukocytosis except when 
the system is overwhelmed by. the poison. Cover-glass preparations made from 
blood may show bacteria, but often fail to do so. Cultures from the blood 
are sterile in most cases, but not in all. A negative finding does not disprove 
the existence of septic infection; a positive finding is of conclusive diagnostic 
value. Pneumococcic septicemia is extremely violent in manifestation. In 
some cases death ensues before the lung has consolidated. If it is not so 
rapid endocarditis, arthritis, peritonitis, meningitis, or osteomyelitis may de- 
velop. 

The prognosis of true septicemia is very unfavorable, and in some malig- 
nant cases death occurs within twenty-four hours, but mild cases often recover. 
Welch points out that finding the staphylococcus pyogenes albus in the blood 
is not particularly ominous, but the presence of other pyogenic cocci is exceed- 
ingly threatening. Endocarditis, pericarditis, peritonitis, pleuritis, broncho- 
pneumonia, empyema, nephritis, arthritis, cholecystitis, hepatitis, meningitis, 
and pyelitis are among the complications which may arise. 

Treatment. — The treatment in general is the same as for septic intoxica- 
tion. Antistreptococcic serum is employed by some surgeons, but the value 
of this method is as yet doubtful. It does not do any harm. It may do 
good. It is proper to use it, but not to the exclusion of other remedies. The 
usual dose is 10 c.c. injected into the abdominal wall. The injection may 
be repeated two, three, or even six times a day, and may be used for a num- 
ber of days. Washing the blood by the intravenous infusion of salt solution 
often produces distinct improvement, which, unfortunately, is usually tempo- 
rary. Dr. C. C. Barrows commends formalin used intravenously. The 
strength of the solution is 1 part of formalin to 5000 parts of salt solution. 
The dose is 500 c.c. I have had no experience with formalin in septicemia, 
but do not believe that any agent can be safely introduced which would rap- 
idly and directly kill the bacteria even if such an agent could be found, the 
attempt to use it would be dangerous as dead bacteria liberate a poison and 
the rapid death of immense numbers of bacteria would mean the entrance into 
the blood of an enormous amount of toxic matter. 

Pyemia. — Pyemia is a condition in which metastatic abscesses arise as 
a result of the existence of septic thrombophlebitis, the disease being char- 
acterized by fever of an intermittent type and by recurring chills. It is not 
actually due to free pus in the blood, but to the passage into the blood of 
clots filled with toxins or, far oftener, infected by streptococci or staphylo- 
cocci, or both. After a wound is inflicted blood clots in the divided veins. 
If suppuration occurs, the clots may become filled with the toxins of pyogenic 
bacteria or be invaded by the bacteria themselves. Thus it becomes evident 



Pyemia 199 

that pyemia may develop with septicemia. It may also develop when there 
is suppuration in a wound, but not septicemia, no lymphatic absorption of 
bacteria or toxins having occurred. A suppurating focus about a vein may 
cause thrombophlebitis and clot-formation even when no wound exists. This 
is seen in thrombophlebitis of the lateral sinus secondary to suppuration of 
the middle ear. 

A vessel thrombus runs up in the lumen of a vein, and the apex of the 
clot softens, a portion of it is broken off by the blood-stream and carried as 
an embolus into the circulation. Many of these poisonous emboli enter into 
the blood and lodge in some vessels which are too small to transmit them, and 
at their points of lodgment form embolic, secondary, or metastatic abscesses. 
If the embolus contains only pyogenic toxins the danger is infinitely less than 
if it contains bacteria. The secondary abscess if caused by a clot containing 
only toxins may not lead to further dissemination of disease. If the embolus 
contains bacteria, thrombophlebitis occurs about it, and new infected emboli 
form and are sent throughout the system. Wounds of the superficial parts 
and bones produce pyemic infarctions and metastatic abscesses of the lungs. 
When these infarctions break into fragments particles may return to the heart 
and lodge, or may be sent out through the arterial system to form other foci 
in distant organs. Infected areas connected with the portal circulation 
(intestinal injuries or suppurating piles) may produce abscess of the liver. 
Wounds of bones which open the medullary cavity or diploic structure are 
particularly apt to be followed by pyemia, and the disease may follow labor, 
phlegmonous erysipelas, and other conditions. Malignant endocarditis is 
called "arterial pyemia, " and is due to endocardial embolic infection. In this 
disorder infected emboli lodge in the kidneys, the spleen, the alimentary tract, 
the brain, or the skin (Osier). Idiopathic pyemia is a misnomer. Some 
primary focus of infection must exist, as was pointed out when discussing 
septicemia. 

Symptoms. — The wound often becomes dry and brown, and sometimes 
also offensive. A severe and prolonged chill or a succession of chills ushers 
in the disease; high fever follows, and drenching sweats occur. The chills 
recur every other day, every day, or oftener. A chill arises from the libera- 
tion and lodgment of emboli. During the sweat the temperature falls and 
may become nearly normal, normal, or actually subnormal. The tempera- 
ture often oscillates violently. The general symptoms of vomiting, wasting, 
etc., resemble those of septicemia. In some cases the mind remains clear, in 
many the delirium is purely nocturnal. The skin frequently becomes jaun- 
diced, and a profound adynamic state is rapidly established. The blood 
changes are like those of septicemia. The spleen is enlarged. The lodgment 
of emboli produces symptoms whose nature depends upon the organ involved. 
Lodgment in the lungs causes shortness of breath and cough, with slight physi- 
cal signs. Lodgment in the pleura or pericardium gives pronounced physical 
evidence. Lodgment in the spleen produces severe pain and great enlarge- 
ment. The parotid gland not unusually suppurates. 

In a suspected case of pyemia always examine an existing wound, and if 
there is no wound, remember that the infection may arise from gonorrhea, 
osteomyelitis, suppuration in the middle ear, appendicitis, dental caries, ton- 
sillar suppuration, abscess of the prostate, etc. Chronic pyemia may last 



200 Erysipelas 

for months; acute pyemia may prove fatal in three days. The chief com- 
plications are joint-suppuration, bronchopneumonia, pleuritis, empyema, 
endocarditis, pericarditis, peritonitis, nephritis, cholecystitis, pyelitis, venous 
thrombosis, and abscesses. 

Treatment. — The treatment is the same as for septicemia. Open, drain, 
and asepticize any wound and any accessible secondary abscess. 



XI. ERYSIPELAS (ST. ANTHONY'S FIRE). 

Erysipelas is an acute, contagious, spreading capillary lymphangitis 
due to the streptococci of erysipelas, which grow and multiply in the smaller 
lymph-channels of the skin and its subcutaneous cellular layers and also in 
the lymph-channels of serous and mucous membranes. Cutaneous erysipelas 
is characterized by a rapidly spreading dermatitis, by a remittent fever due 
to absorption of toxins, and by a tendency to recurrence. It is always pre- 
ceded by a wound, a scratch, or an abrasion, which may have been trivial and 
may never have been noticed. The so-called idiopathic erysipelas is pre- 
ceded by a breach of surface continuity so small as to escape notice. The 
initial point of infection may be in the mouth, the nostril, the pharynx, the 
auditory meatus, between the fingers or toes, at the margin of a nail, or in a 
cutaneous furrow. The involved area in cutaneous erysipelas seldom suppu- 
rates but sometimes does, very thin or watery pus being formed. If thick 
pus forms it means mixed infection with staphylococci, but the formation of 
thin pus does not require a mixed infection, as the streptococcus is identical 
with the streptococcus pyogenes. In some cases of erysipelas, staphylococcus 
infection follows and even actually replaces streptococcus infection. The 
rapid spread of erysipelas is due to the fact that the streptococci prevent coagu- 
lation of exudate and are not actively attacked by leukocytes. Erysipelas 
is most common in the spring and fall, and is most usually met with among 
those who are crowded into dark, dirty, and ill-ventilated quarters; it attacks 
by preference the debilitated and broken-down (as alcoholics and sufferers 
from Bright's disease). The disease may become endemic in special places 
or localities. The poison of erysipelas will produce puerperal fever in a lying- 
in woman. The streptococcus was first obtained in pure cultures by Feh- 
leisen. This organism is widely diffused. The .question of identity with the 
streptococcus pyogenes is discussed on page 44. 

Forms 0) Erysipelas. — Ambulant, erratic, migratory, or wandering erysipe- 
las is a form which tends to spread widely over the body, leaving one part and 
going to another. Bullous erysipelas is attended by the formation of bullae. 
In diffused erysipelas the borders of the inflammation gradually merge into 
healthy skin. Erythematous erysipelas involves the skin superficially. Meta- 
static erysipelas appears successively in various parts of the body. Puer- 
peral erysipelas begins in the genitals of lying-in women, producing puerperal 
fever. Erysipelas simplex is the ordinary cutaneous form. Erysipelas 
neonatorum begins in the unhealed navel of a newborn child and spreads 
from this point. Typhoid erysipelas occurs with profound adynamia. Uni- 
versal erysipelas involves the entire body. Cellulitis is often erysipelas of the 
subcutaneous layers. Phlegmonous erysipelas involves the skin and the 



Cutaneous Erysipelas 201 

cellular tissues, and causes suppuration, and often gangrene. Edematous 
erysipelas is a variety of phlegmonous erysipelas with enormous subcutaneous 
edema. Lymphatic erysipelas is characterized by rose-red lines due to lym- 
phangitis. 1 'cnoits erysipelas is marked by the dark color of venous congestion. 
Mucous erysipelas involves a mucous membrane. Erysipelas may attack 
the fauces, producing the very grave condition known as fancied erysipelas. 

Clinical Forms. — The clinical forms are cutaneous erysipelas; cellulo- 
cutaneous or phlegmonous erysipelas; cellulitis, and mucous erysipelas. 

Cutaneous erysipelas most frequently attacks the face. A fever sud- 
denly appears, rises rapidly, reaches a considerable height, is remittent in 
type and sometimes distinctly fluctuating, and usually terminates in four or five 
days by crisis. At the time of febrile onset spots of redness appear on the 
skin. These spots run together, and soon a large extent of surface is found 
to be red and a little elevated. Any wound, ulcer, or abrasion which exists 
becomes dry and unhealthy, and its edges redden and swell. The erysipe- 
latous area of redness and swelling extends either in spots with intervening 
healthy skin or in an uninterrupted line. The margin is usually sharply 
defined from the healthy skin, and the color fades at the original focus as the 
disease advances at the periphery of the red area. The color fades at once 
on pressure and returns at once when pressure is removed. There is slight 
burning pain, which is increased by pressure. In the hyperemic area vesicles 
or bullae form, containing first serum and later it may be sero-pus, but there 
is rarely genuine suppuration in cutaneous erysipelas. Edema affects the 
subcutaneous tissues, producing great swelling in regions where there is much 
loose cellular tissue (as in the eyelids). The anatomically related lymphatic 
glands may become large and tender. In an ordinarily strong person the 
color of an erysipelatous area is bright red or more rarely dark red. A duskv 
color precedes suppuration. A blue color precedes gangrene or indicates pro- 
found cardiac and pulmonary involvement. Erysipelas spreads now in one 
direction, now in another, influenced, acccording to Pfleger, by the furrows 
of the skin. When the disease ceases to spread, the swelling and redness 
gradually abate, and after they disappear desquamation takes place, and the 
blebs become dry and crusted. 

In strong subjects the constitutional symptoms of cutaneous erysipelas are 
usually slight. In the old and debilitated the symptoms are typhoidal, there 
is a dry tongue, dyspnea, and hebetude, delirium comes on, and death is 
usual. Possible complications are meningitis, pneumonia, septicemia, pleuri- 
tis, pyemia, endocarditis, arthritis, and albuminuria. Erysipelas neonatorum 
is generally fatal. In some instances an attack of erysipelas will cure an old 
skin eruption, a new growth, an ulcer, or an area of lupus. This is the ery- 
sipele salutaire of our French confreres. 

Treatment. — Isolate the patient, asepticize the wound, if there be a wound, 
and administer a purge. Cases of cutaneous erysipelas occurring in a fairly 
healthy, young or middle-aged subject, tend to get well without treatment. 
If a person is debilitated, free stimulation is necessary. Tincture of chlorid 
of iron is usually administered in doses of from 20 to 40 n\ three times a 
day. Tonic doses of quinin are also given. Nutritious food is given at 
intervals of three or four hours. For sleeplessness or delirium use chloral or 
the bromids ; for very high temperature, cold sponging is required. To prevent 



202 Erysipelas 

spreading some have advised injection of the healthy skin near the blush 
with a 2 per cent, carbolic solution or with fluid containing gr. y 1 ^ of corrosive 
sublimate. A band of iodin painted on the skin may arrest the progress of 
the disease, and so may a ring streaked around a limb or about an erysipe- 
latous area by lunar caustic. Kraske has suggested a method of preventing the 
spread of cutaneous erysipelas which is often effective. The patient is anes- 
thetized. At about two inches from the margin of the redness a series of 
cuts are made into the skin, to a sufficient depth to cause free oozing. Each 
cut is crossed by another cut and a ring of scarifications is made to surround 
the region of the erysipelas. After the oozing ceases the scarified area is 
soaked for one hour with a solution of carbolic acid (i : 20) or corrosive 
sublimate (1 : 2000). The part is dressed with pads wet with carbolic acid 
(1 : 40) or corrosive sublimate (1 : 2000). This operation causes the forma- 
tion of a protective barrier of leukocytes. Locally, paint the inflamed area 
with equal parts of iodin and alcohol and apply lead-water and laudanum. 
The iodin is germicidal and quickly enters the lymph-spaces. The lead- 
water and laudanum allays the burning pain. If an extremity be involved, 
bandage it. Some advocate a daily inunction of Crede's soluble silver. A 
good application is a 50 per cent, ichthyol ointment with lanolin. A very 
useful method is von Nussbaum's. The author applies it somewhat modi- 
fied, as follows: wash the part with ethereal soap, irrigate with a solution of 
corrosive sublimate (1 : 1000), dry with a sterile towel, apply an ointment of 
ichthyol and lanolin (50 per cent.), and dress with antiseptic gauze. Some 
use iced-water cloths. Hot fomentations are distinctly harmful. Some 
apply borated talc or salicylated starch. Ringer advised painting every three 
hours with a mixture composed of gr. xxx of tannic acid, gr. xxx of camphor, 
and 5iv of ether. J. M. DaCosta recommended pilocarpin internally in the 
beginning of a case. Antistreptococcic serum has been used in erysipelas, 
and great results have been claimed for it. It is asserted that under its influ- 
ence the temperature soon becomes normal. My personal experience with 
the serum treatment has not convinced me of its value, although some cases 
seem to be benefited. 

Cellulocutaneous or phlegmonous erysipelas is characterized by high 
temperature (io4°-io6° F.), the rapid onset of grave prostration, irregular 
chills, sweats, and a strong tendency to delirium. The constitutional condition 
may be one of suppurative fever, sapremia, septicemia, or pyemia. The parts 
are red, as in cutaneous erysipelas, and the tumefaction is vastly greater. The 
swelling is brawny, comes on early, increases with exceeding rapidity, induces 
a high degree of tension, and frequently becomes associated with sloughing 
or even cutaneous gangrene. The lymphatic glands are swollen, but the in- 
flamed lymphatic vessels are hidden by the tumefaction. In most cases 
suppuration occurs, and when this happens the parts become boggy and the 
pus is widely disseminated in the subcutaneous and intramuscular tissues, 
and even into muscle-sheaths and tendon-sheaths (purulent infiltration). 
When the disease abates sloughs form, which leave ulcers upon being cast off. 
In bad cases muscles, vessels, tendons, and fascia may slough away. The 
commonest complications are suppression of urine, bronchopneumonia, con- 
gestion and edema of the lungs, meningitis, congestion of the kidneys, and 
acute pleurisy. Septicemia or pyemia may occur. We sometimes meet with 



Cellulitis 203 

this form of erysipelas after extravasation of urine. It is not a pure strepto- 
coccus infection. There is a mixed infection with other pyogenic cocci, and 
often with organisms of putrefaction. 

Treatment. — At once asepticize and drain any existing wound, and dress 
such a wound with hot antiseptic fomentations. If there are inflamed lymph- 
vessels or glands above the area of cellulocutaneous infection, paint the skin 
above them with iodin and smear it with blue ointment or rub in Crede's 
ointment of soluble silver. Make numerous incisions into the inflamed 
tissues. These incisions should be near together, and each cut should be 
two or three inches long. Spray the wounds with hydrogen peroxid by means 
of an atomizer, wash with corrosive sublimate solution (1 : 1000), and pack 
each wound with iodoform gauze. Dress with many layers of gauze wet with 
a hot solution of corrosive sublimate. The gauze is covered with a rubber dam 
and a hot- water bag is laid upon the dressing. If sloughs form, cut them away 
and employ hot antiseptic fomentations. Change the dressings often. In 



Fig. S3. — Acute cellulitis of palm and forearm following- a slight wound. 

some cases it may be necessary to employ continuous irrigation with warm 
antiseptic fluid, or continuous immersion in a hot aseptic or antiseptic bath. 
It is not unusually necessary to operate for the removal of enlarged lymphatic 
glands. In rare cases amputation is demanded. When granulations begin 
to form, treat as a healing wound. The constitutional treatment is that pre- 
viously set forth as applicable to septicemia, viz., purgation, the use of diuretics 
and diaphoretics, the administration of strychnin, quinin, digitalis, alcoholic 
stimulants, and nourishing food. Antistreptococcic serum may be employed. 
In severe cases employ hypodermoclvsis or saline infusion into a vein. 

Cellulitis. — Cellulitis (Fig. 88) is a microbic inflammation of the cellular 
tissue. It may be due to staphylococci, to streptococci, to other pyogenic 
bacteria, or to mixed infection with two varieties of pyogenic organisms. The 
commonest form is streptococcus infection, and this is a variety of erysipelas. 
A streptococcus infection may be followed and replaced by a staphylococcus 
infection. Infection with the bacillus aerogenes capsulatits causes gangrenous 
cellulitis. Cellulitis is prone to arise in damaged tissues, for instance, in 



204 Tetanus, or Lockjaw 

a crushed part, a limb the seat of a compound fracture, or tissue containing 
extravasated urine. In tissue the resistance of which has been lessened by 
diabetes, Bright's disease, irritating discharges, or trophic lesions, cellulitis 
is rather apt to develop. In cellulitis of the subcutaneous tissue the micro- 
organisms find entrance by means of a wound. Swelling precedes redness. 
The swelling is not so marked as in phlegmonous erysipelas, and the redness is 
darker and is less distinct than in cutaneous erysipelas. The redness of 
cellulitis is about the wound ; it spreads but does not fade at the center as does 
ordinary erysipelas; red lines due to lymphangitis ascend the limb from the 
infected wound, and the anatomically associated lymphatic glands enlarge. 
In the wound and its neighborhood there is severe throbbing pain. The 
constitutional symptoms of infection develop rapidly. In trivial cases the 
lymphatics dispose of the poison and suppuration does not occur. In severe 
cases pus forms about the wound and lymphatic glands may suppurate. Phleg- 
monous erysipelas may develop, and septicemia or pyemia may arise. 

Treatment. — Open, disinfect, and drain the wound. Paint iodin upon 
the skin over inflamed lymphatic vessels and glands and cover with ichthyol 
ointment or rub Crede's soluble silver ointment into the skin over the inflamed 
lymph-glands and vessels. Dress the wound and the adjacent inflamed area 
with hot antiseptic fomentations. Secure rest of the part. It may be neces- 
sary to make incisions as in phlegmonous erysipelas. In some cases it is 
necessary to remove breaking-down glands. The constitutional treatment is 
that employed for septicemia. 



XII. TETANUS, OR LOCKJAW. 

Tetanus is a microbic disease invariably preceded by some injury and 
characterized by spasm of the voluntary muscles. The wound may have been 
severe, it may have been so slight as to have attracted no attention, it may 
have been inflicted upon the alimentary canal by a fish-bone or other foreign 
body, or may have been situated in the nose, urethra, vagina, or ear. It is 
possible that infection can occur through a mere abrasion of a mucous mem- 
brane. The so-called idiopathic tetanus is either not tetanus at all, or the 
term expresses the fact that we have not found the traces of an injury which 
did exist. Tetanus arises most frequently after punctured and particularly 
after lacerated wounds of the hands or feet. In a surgical experience of twenty 
years in connection with the Philadelphia Fire Department I have known 
hundreds of firemen to injure their feet by stepping on nails and not one 
developed tetanus. In fact, the only case of tetanus among them since 
187 1 arose in a man who lacerated his hand with glass. Before tetanus 
appears a wound is apt to suppurate or slough; but in some instances the 
wound is found soundly healed when the tetanus begins. The toy pistol 
produces a peculiarly dangerous wound. In the United States many 
cases of tetanus follow the celebration of the Fourth of July, a large per cent, 
of the causative wounds being from the toy pistol. The Fourth of July, 
1903, was responsible for 466 reported and no one knows for how many 
unreported cases in the United States. The fact that the bacillus of tetanus 
is anaerobic explains the comparative frequency with which punctured and 
lacerated wounds are attacked, for in such wounds the bacilli are deeply 



Tetanus, or Lockjaw 205 

lodged in recesses or cavities into which air does not penetrate or are covered 
with discharges which exclude air. Suppuration favors the growth of tetanus 
bacilli, because the pyogenic organisms consume oxygen. Occasionally, 
though fortunately very rarely, tetanus follows vaccination. It is essential 
that vaccine virus should be carefully selected and prepared. When care 
is taken, the operation is absolutely safe. When tetanus follows vaccination, 
it arises from infection of the wound either at the time of vaccination or, 
as is common, at a later period from scratching or some other fouling. Tet- 
anus has followed the injection of gelatin. Commercial gelatin often contains 
the bacilli and should never be used without careful fractional sterilization 
(page 363). Tetanus may appear within twenty-four hours after an accident, 
but it may not arise until many days or even several weeks have elapsed. 
Rose reported a case which began within twenty-four hours. Kuhn ("Berliner 
klinische Wochensch.," 1901) reports a fatal case of tetanus beginning twelve 
hours after an injection of gelatin. Such a rapid case could only be due to the 
gelatin having contained a large quantity of tetanus toxin (Schuckmann). 
Samuel D. Gross, in his "System of Surgery," speaks of one case occurring 
in a man five weeks after injury, and another in a girl four weeks after injury. 
Jacobson and Pease are of the opinion that "such cases as have been recorded 
with periods of incubation under three days must be accepted with considerable 
reserve " ("Annals of Surgery," Sept., 1906). Tetanus prevails more in certain 
localities than in others. Colored people are very susceptible, and the disease 
may exist endemically, and does so in certain portions of New Jersey and of 
Cuba. In our country the greatest prevalence, according to Anders, is in 
Pennsylvania, Northern New York, Long Island, Virginia, Georgia, and 
Louisiana. Anders collected 1201 cases and Pennsylvania stands first on 
his list with 224 cases ("Jour. Am. Med. Assoc," July 29, 1905). Tetanus 
is due to the growth in a wound of a bacillus which was first described by 
Nicolaier and was first cultivated by Kitasato. It is the most widely distrib- 
uted of all the pathogenic bacteria. It is very difficult to cultivate and 
cannot be cultivated at all unless air is absolutely excluded. Tetanus bacilli 
or their spores are found particularly in garden soil, in the dust of walls, walks, 
and cellars, in street dirt, and in the refuse of stables. There is much sug- 
gestive evidence that virulent tetanus bacilli come from the intestinal canal 
of animals; that the bacteria lose their virulence when long outside of the 
intestinal canal; and that the highest degree of virulence is obtained by 
those which have passed frequently through intestinal canals. The above 
view is known as the fecal theory and is strongly advocated by Somani.* 

In tetanus the bacilli do not enter into the blood and toxic products pro- 
duced by them are not directly absorbed by the blood or lymph. The toxic 
products alone without any bacteria enter the muscular end organs of motor 
nerves, ascend within the nerves and reach the spinal cord and 
medulla (Brunner, Marie), become fixed in the nerve-cells of the spinal 
cord and medulla, and produce the symptoms of the disease. Hence 
tetanus is an intoxication and not an infection, and a drop of blood of an 
animal with tetanus, if injected into another animal, will not produce the 
disease. Tetanus toxin poisons the nervous system as would strychnia or 
some other vegetable alkaloid. It is probably the most powerful of known 

* " Yerhandl. d. 10. internat. med. Cong.," Berlin, 1890, Bd. v, Abth. 15, p. 152. 



206 Tetanus, or Lockjaw 

poisons. It has been estimated that yts of a grain is sufficient to kill an adult 
weighing 165 pounds ("American Medicine," Nov. 30, 1901). The great 
power of the poison is shown by the report of Dr. Nicholas's case ("Comptes 
rendu de la Societe de Biologie," 1893). Dr - Nicholas had been using a 
syringe to inject filtered cultures of the bacilli of tetanus and he accidentally 
pricked his finger with the needle. In four days tetanus began, and the 
Doctor barely escaped with his life in spite of the fact that the fluid was 
free of bacteria and the dose of toxin was extremely minute. The nature of 
the virulent poison which is produced at the seat of inoculation is uncertain. 
Some believe it to be alkaloidal, like the vegetable alkaloids; some that it is 
a toxalbumin, others maintain that it is an enzyme or ferment (Nocard, 
Courmont, and others). In a very few instances the injection of perfectly 
sterile antidiphtheritic serum into human beings has caused death with all 
the symptoms of tetanus. The serum must have been obtained from horses 
in whom tetanus was incubating, and the blood-serum injected must have 
contained a fatal dose of tetanus toxin. In tetanus an ascending neuritis 
occasionally, though seldom, exists in the peripheral nerve near the lesion. 
The toxin is carried to the cord by the motor nerves only, and it is not only 
absorbed by the lymph-channels of the nerve but ascends along the axis-cylin- 
ders of the nerve itself and reaches the motor cells of the spinal cord (Meyer 
and Ransom, in "Arch, exper. Path. u. Pharmakol," 1903). On reaching 
the cord it attacks the motor nerve-cells, producing changes similar to those 
involved in certain infections, and ascends in the motor tracts of the cord to 
the medullary nerve-centers. While toxin is ascending the axis-cylinders 
a certain amount is taken up by the lymphatics, enters the blood, and reaches 
the spinal cord by other nerve-fibers (Jacobson and Pease, in "Annals of 
Surgery," Sept., 1906). The essential basis of tetanus is spreading irritation of 
the motor portion of the spinal cord accompanied by extreme reflex excitability 
which is due to poisoning of sensory neurones (Meyer and Ransom). The 
irritation of the motor cord produces tonic contraction of the muscles; the 
excitation of the sensory neurones is responsible for clonic convulsions. 

Local Tetanus. — In some cases local symptoms precede widespread 
evidences of tetanus. Experimental tetanus in animals "exhibits almost 
without exception as its earliest manifestations those of a purely local charac- 
ter and which are at first restricted to the neighborhood of the inoculation. 
This is now understood to be due to the absorption of the toxin by the motor- 
nerve of the part. The conditions favoring the local appearance of tetanus 
are a short motor nerve as in head injuries; an injury to a nerve-trunk per- 
mitting the rapid absorption of a large amount of toxin; the production of 
a meager amount of toxin or the presence of something which prevents the 
admission of a large amount of toxin into the circulation (Nathan Jacobson 
and Herbert D. Pease, in "Annals of Surgery," Sept., 1906). Cases with local 
symptoms in the beginning are apt to have had long periods of incubation, 
are apt to be cured, and usually endure a considerable time. 

Symptoms. — Acute tetanus begins within ten days of an accident. 
The usual period of incubation is from three to five days. In most cases the 
first symptom is stiffness of the jaw on opening the mouth. In some cases 
the first symptom is stiffness of the neck, and the patient believes he has 
"caught cold." In any case the neck soon becomes stiff, and finally both 



Symptoms of Tetanus 207 

the neck and jaw become as rigid almost as iron. The fixation of the jaw is 
called trismus. The muscles of deglutition become rigid on attempts at swal- 
lowing. The muscles of the back, legs, and abdomen are thrown into tonic 
spasm, but the arms rarely suffer. If the infected injury is on the hand or foot, 
that extremity usually is found to be rigid. Spasm of the face muscles causes 
the risus sardonicus, or sardonic smile (contraction particularly of the mus- 
culits sardonicus of Santorini). The contraction of the muscles of the back 
is often so powerful as to bend the patient into a curve like a bow and allow 
him to rest only on his occiput and heels. This condition is known as opisthot- 
onos. If he is bent forward, so that the face is drawn to the legs, it is called em- 
prostliotonos. If his body is curved sideways, it is designated pJeurosthotonos. 
An upright position is orthotonos. The spasm may be so violent as to cause 
muscular rupture. 

The characteristic condition in tetanus is one of widely diffused tonic 
spasm, aggravated frequently by clonic spasms arising from peripheral irri- 
tations. These irritations may be draughts, sounds, lights, shaking of the 
bed, attempts at swallowing, contact of the bed-clothing, the presence of urine 
in the bladder or of feces in the rectum, or various visceral actions. The clonic 
spasms begin early in the case and become more frequent and more violent 
as the disease progresses. The muscles become more rigid and the attitude 
produced by the tonic contraction of the muscles is temporarily exaggerated. 
The forcible contraction of the jaw may loosen or break teeth. The spasms 
of the diaphragm, of the glottis, and of the muscles of respiration .may produce 
death and always produce great dyspnea. The man laboring under a tetanic 
convulsion presents a dreadful picture; he is bent into some unnatural atti- 
tude, the face is cyanotic and wet with drops of sweat, the lips are covered 
with froth which is often bloody, the eyes bulge and are suffused, and the 
countenance expresses deadly terror and suffering. The agonizing "girdle 
pain " so often met with is due to spasm of the diaphragm. Each clonic spasm 
causes a hideous scream by the constriction of the chest forcing air through 
a contracted glottis. During the progress of the disease constipation is 
persistent, and retention of urine is the rule (because of sphincter spasm). 
The mind is entirely clear until near the end — one of the worst elements of 
the disease. Swallowing in many cases is impossible. Talking is very 
difficult and it is impossible to project the tongue. The muscles throughout 
the body feel very sore. The temperature may be normal, but it is usually 
a little elevated, and always rises just before death. Hyperpyrexia sometimes 
occurs (io8°-no° F.), and the temperature may even ascend for a time after 
death. Insomnia is obstinate. In between 80 and 90 per cent, of cases of 
acute tetanus death occurs within five days, and many of these patients die 
within two or three days. Of late years the mortality in acute tetanus has 
slightly diminished. If a patient lives a week, his chance of recovery is good. 
Death may be due to exhaustion or to carbonic-acid narcosis from spasm of 
the glottis or fixation of the respiratory muscles. 

Chronic tetanus comes on late after a wound (from ten days to several 
weeks). The symptoms are not so severe as in acute tetanus. The muscular 
spasm is widespread, but it may not be persistent, intervals of relaxation 
permitting sleep and the taking of food. Chronic tetanus long had a mor- 
tality of 40 or 50 per cent., but modern methods of treatment, it has been 



2 o8 



Tetanus, or Lockjaw 



claimed, have considerably reduced it. According to the report of 
Jacobson and Pease it is still from 35 to 50 per cent. ("Annals of 
Surgery," Sept., 1906). The disease may last for some weeks. Trismus 
neonatorum, or trismus nascentium, the lockjaw of the newborn, is due to 
infection of the stump of the umbilical cord, and is practically invariably 
fatal. Hydrophobic tetanus, head tetanus, or cephalic tetanus, is a condition 
in which the spasms are confined chiefly to the face, pharynx, and neck, 
although the abdominal muscles are usually also rigid, and in which there 
is palsy of the seventh nerve. It follows head-injuries, and gives a better 
prognosis than does general tetanus. 

Two other forms of tetanus have been produced in animals by experi- 
menters. One is cerebral tetanus, produced by injecting tetanus toxin into 
the brain and characterized by mental symptoms (Roux and Borrell, in "An- 
nals Ins. Pasteur," July, 1897). Another is tetanus dolorosa, produced by- 
injecting toxin into the posterior roots of the spinal nerves, and characterized 
by violent spasms of pain without motor symptoms. 

Diagnosis. — Tetanus may be confounded with strychnin-poisoning, 
with hysteria, with tetany, or with hydrophobia. Wood's table makes the 
diagnosis clear between tetanus, strychnin-poisoning, and hysteria.* 



Tetanus. 



Muscular symptoms 
usually commence with 
pain and stiffness in the 
back of the neck, some- 
times with slight muscu- 
lar twitching; comes 
on gradually. Jaw one 
of the earliest parts 
affected; rigidly and per- 
sistently set. 

Persistent muscular 
rigidity very generally, 
with a greater or less 
degree of permanent 
opisthotonos, empros- 
thotonos, pleurosthoto- 
nos, or orthotonos. 

Consciousness pre- 
served until near death, 
as in strychnin-poison- 
ing. 



Hysterical Tetanus. 



Commences with blind- 
ness and weakness. 



Muscular symptoms 
commence with rigidity of 
the neck, which creeps 
over the body, affecting the 
extremities last. Jaws 
rigidly set before a convul- 
sion, and remain so be- 
tween the paroxysms. 



Persistent opisthotonos 
and intense rigidity be- 
tween the convulsions and 
after the convulsions have 
ceased, the opisthotonos 
and intense rigidity last- 
ing for hours. 

Consciousness lost as 
the second convulsion 
comes on, and lost with 
every other convulsion, the 
disturbance of conscious- 
ness and motility being 
simultaneous. 



Strychnin-poisoning. 



Begins with exhilaration and rest- 
lessness, the special senses being 
usually much sharpened. Dimness 
of vision may in some cases be 
manifested later, after the develop- 
ment of other symptoms, but even 
then it is rare. 

Muscular symptoms develop very 
rapidlv, commencing in the extremi- 
ties, or the convulsion when the dose 
is large seizes the whole body simul- 
taneously. Jaw the last part of the 
body to be affected; its muscles re- 
lax first, and even when, during a 
severe convulsion, it is set, it drops 
as soon as the latter ceases. 

Muscular relaxation (rarely a 
slight rigidity) between the convul- 
sions, the patient being exhausted 
and sweating. If recovery occurs, 
the convulsions gradually cease, 
leaving merely muscular soreness, 
and sometimes stiffness like that 
felt after violent exercise. 

Consciousness always preserved 
during convulsions, except when the 
latter become so intense that death 
is imminent from suffocation, in 
which case sometimes the patient 
becomes insensible from asphyxia, 
which comes on during the latter 
part of a convulsion and is almost a 
certain precursor of death. 



* "Nervous Diseases," by Prof. H. C. Wood. 



Treatment of Tetanus 



209 



Tetanus. 



Hysterical Tetanus. 



Strychnin-poisoning. 



Draughts, loud noises, 
etc., produce convul- 
sions, as in strychnin- 
poisoning; may com- 
plain bitterly of pain. 

Eyes open and rigidly 
fixed during the convul- 
sion. 



Crying spells alternating 
with convulsions. 



Eves closed. 



Partial spasm in the leg, 
producing in Wood's cases 
crossing of the feet and 
inversion of the toes. If 
all the muscles were in- 
volved, eversion would oc- 
cur, as the muscles of ever- 
sion are the stronger. 



The "slightest breath of air" 
produces convulsion. Patient may 
scream with pain or may express 
great apprehension, but "crying 
spells" would appear to be impos- 
sible. 

Eyes stretched wide open. 



Legs stiffly extended with feet 
everted, as the spasms affect all the 
muscles of the leg. 



Tetany is distinguished from tetanus by the milder nature of the spasms, 
by the greater limitation of the rigidity, by the fact that spasms begin in the 
hands or feet, not in the jaw and neck, and in most cases by periods of dis- 
tinct intermittence. 

In hydrophobia tonic spasm does not exist, and if clonic spasms occur 
they are secondary to suffocative attacks. 

Treatment. — Far better even than to treat tetanus well is to prevent it. 
Careful antisepsis will banish it as a sequence of surgical operations as thor- 
oughly as it has banished septicemia. Every infected wound must be dis- 
infected with the most scrupulous care. Every punctured wound is to be 
incised to its depths and thoroughly cleaned and drained. In a very sus- 
picious wound, such as a Fourth of July injury or a wound from a dung 
fork, or the entrance into the tissues of a splinter from a stable floor, after 
the removal of foreign bodies and thorough antiseptic cleansing, dust the wound 
with antitoxin powder (McFarland) or give antitoxin hypodermatically. 
It seems reasonably certain that tetanus antitoxin has prophylactic power, 
in fact, Jacobson and Pease say that, " as a prophylactive measure it merits 
our fullest confidence" ("Annals of Surgery," Sept., 1906). Obviously, 
this cannot be done for every wound. The procedure is not a cer- 
tain preventative. Reynier injected antitoxin into a patient on whom he 
was about to operate because there was a case of tetanus in the wards and yet 
this man developed tetanus (" Gaz. des Hopitaux, " July 16, 1901). Neverthe- 
less it is sure that animals can be rendered immune to tetanus, and the pro- 
phylactic power of antitoxin is warmly advocated by many eminent men. (See 
F. L. Taylor, in "N. Y. Med. Journal," July 20, 1901.) Puerperal tetanus 
is prevented by antiseptic midwifery, and tetanus neonatorum is obviated 
by the antiseptic treatment of the stump of the cord. In order to obviate 
all danger of the development of tetanus during vaccinia, perform the little 
operation with cleanliness and care properly for the wound and for the pustule. 
The skin should be cleansed with soap and water, rubbed with alcohol, and 
washed with boiled water. It should be gently scraped with a knife (which 
has been boiled) until serum exudes. The virus, taken from a hermetically 
sealed tube, is applied to the raw surface, and allowed to remain exposed to 
14 



210 Tetanus, or Lockjaw 

the air until dry. A piece of sterile gauze is laid over the part and is held in 
place by a bandage. This dressing is changed once or twice a day as may be 
necessary, and is used until granulation begins, at which time the use of any 
simple ointment is admissible. Do not apply a shield. The evil of shields is 
pointed out by Robert N. Willson ("American Medicine," Dec. 7, 1901). 

When tetanus exists, always look for a wound, and if one is found, open 
it; if there are sloughs, cut them away, wash the wound with peroxid of 
hydrogen and then with hot normal salt solution, dry the wound with gauze, 
paint the surfaces of the wound with bromin, and secure drainage by packing 
with iodoform gauze. Dennis disinfects the wound with a solution of tri- 
chlorid of iodin (0.5 per cent.). 

Surgeons of a former day were accustomed to amputate for tetanus if the 
wound was upon an extremity. When we reflect that the poison-producers 
are in the wound and not in the circulation, it seems a reasonable treatment. 
As a matter of fact, it never does any good, because, when the symptoms 
begin, the toxin has already entered into the nerve-cells and become fixed. 
Kitasato has shown that if a mouse is inoculated with tetanus near the root of 
the tail, excision of the tail and cauterization of the stump will not prevent 
tetanus unless it is performed within one hour of the inoculation; and Nocard 
inoculated sheep near the root of the tail with tetanus spores, and although 
the moment symptoms appeared he amputated well above the point of inocu- 
lation, the animals died of the disease. We must regard amputation as a 
useless method of treatment. 

Keep the sufferer from tetanus in a darkened, well-ventilated, and quiet 
apartment, so as to exclude as far as possible peripheral irritation. Watch for 
the occurrence of retention of urine, and use the catheter if necessary. Secure 
movements of the bowels by administering salines, castor oil, croton oil, or 
enemas. Stimulate freely with alcohol. Give plenty of concentrated liquid 
food unless swallowing causes convulsions, then feed by the rectum, and give 
fluids by hypodermoclysis. If swallowing causes convulsions some surgeons 
give an inhalation of nitrite of amyl before an attempt is made to swallow. 
If this treatment does not make swallowing possible then partially anesthetize 
the patient and feed him by means of a pharyngeal tube passed through the 
nose. Better than either of these plans is to abandon mouth feeding. Large 
doses of the bromid of potassium, or of this drug with chloral, give the best 
results, as far as drug treatment is capable of giving results. If bromid is 
used, give about oj every four to six hours. Other drugs that have been 
used with some success are gelsemium, morphin, curare, injections and fomen- 
tations of tobacco, physostigmin, anesthetics, cocain, and cannabis indica. 
An ice-bag to the spine somewhat relieves the girdle pain. Hot baths have 
been advised. It is said that venesection followed by the intravenous infusion 
of saline fluid does good. This procedure is followed by a free flow of urine 
and by lessening of the number of the paroxysms. It may be repeated several 
times during a few days (E. J. McOscar, in "American Medicine," Sept. 
14, 1901; A. V. Moschcowitz, in "Med. News," Oct. 13, 1900). 

Yandell says, in summing up Cowling's report on tetanus:* "Recoveries 
from traumatic tetanus have been usually in cases in which the disease occurs 
subsequent to nine days after the injury. When the symptoms last fourteen 
* American Practitioner, Sept., 1870. 



Treatment of Tetanus 211 

days, recovery is the rule, apparently independent of treatment. The true 
test of a remedy is its influence on the history of the disease. Does it cure 
cases in which the disease has set in previous to the ninth day? Does it fail 
in cases whose duration exceeds fourteen days? No agent tried by these 
tests has yet established its claims as a true remedy for tetanus."* 

It is now claimed by some observers that we have a remedy which fulfils 
the requirements of Yandell in the tetanus antitoxin serum. Behring's 
serum is said to be six times as strong as Tizzoni's, but it is difficult or impos- 
sible to estimate the exact power of either. Behring and Kitasato succeeded 
in immunizing animals and Tizzoni and Cattani discovered that the anti- 
toxin is an enzyme. The antitoxin destroys the activity of the toxin and is 
obtained from an immunized horse. 

If injected subcutaneously it is absorbed very slowly and even twenty- 
four hours or more after such an injection a considerable amount remains 
unabsorbed in the tissues. It is not absorbed at all by the nervous structures. 
It is eliminated rapidly and unaltered in the urine, feces, and sweat. It seems 
to be harmless and its immunizing powers are certain. Its curative power is 
very much less active. Hypodermatic injections are practically useless. In- 
travenous injections are of more service, but even then the antitoxin only 
grasps the toxin in the blood and fails to reach that in the nerves, nerve-cells, 
and nerve tracts. Some practice intramuscular injections, but 7 acute 
cases so treated died, a mortality of 100 per cent. (Jacobson and Pease, "Annals 
of Surgery," Sept., 1906). Injection into the theca of the cord (intraspinal 
injection) by means of lumbar puncture is an attractive method but the 
inability of nerve-elements to absorb antitoxins when the pia intervenes, is 
an argument against it, though in one violent acute case of my own, occur- 
ring in a boy, recovery followed this method. In 7 acute cases treated by 
this method the mortality was 57.1 per cent. (Jacobson and Pease, in "Annals 
of Surgery," Sept., 1906). John Rodgers injected antitoxin into the cauda 
equina and nerves and cured two apparently hopeless cases ("Med. Record," 
Julv 2, 1904). Injection into a nerve (intraneural injection) is a more rational 
method, but even this plan is only of service in localized tetanus, the main 
nerve above the part tetanized being injected (Kiister, in German Surgical 
Congress of 1905). However antitoxin is given the dose must be large if any 
good is to be done. Serum is usually prepared as follows: A horse is injected 
repeatedly with the toxins obtained from cultures of tetanus bacilli, the strength 
of the injections being gradually increased. Eventually the animal becomes 
immune to tetanus. Some days after the final injection a cannula is placed 
in the jugular vein of the immunized animal, blood is drawn into a sterile 
vessel and is permitted to coagulate during twenty-four hours, and at the end 
of this period the serum is separated from the clot, is evaporated to dryness in 
a vacuum over sulphuric acid, and the powder is placed in hermetically sealed 
glass tubes. In order to use the serum, dissolve the powder in sterile water, in 
the proportion of 1 gm. to 10 c.c. The fluid serum sold in the shops bears 
this proportion to the powder. The serum can be given subcutaneously or 
intravenously, or can be injected into the brain or under the cerebral dura or the 
spinal arachnoid, or into a nerve. If used subcutaneously, from 20 to 30 c.c. of 
the fluid serum should be injected into the abdominal wall, and this dose should 
* Quoted by Hammond, in his "Diseases of the Nervous System." 



212 Tetanus, or Lockjaw 

be given every six or eight hours until there is improvement. Then from 5 to 10 
c.c. should be given every six or eight hours. As the symptoms abate the dose 
is lessened and the intervals between the doses are increased. In a violent 
case of tetanus the first dose should consist of 40 to 50 c.c, and this can be 
repeated in four or five hours. In a case of tetanus which recovered, reported 
by Mixter, enormous doses were given. This patient received in the aggre- 
gate 3400 c.c. of serum, or 285 c.c. a day.* In 47 acute cases treated by 
subcutaneous injection the mortality was 82.6 per cent. In 30 acute cases 
treated by a combination of either subcutaneous, intraspinal, intravenous, or 
intracranial injections the mortality was 93.1 percent. (Jacobson and Pease, 
in "Annals of Surgery," Sept., 1906). Roux and Borrel maintain that the 
toxins of tetanus pass from the blood into nervous tissue and are fixed in the 
nerve-cells. As the antitoxin when given hypodermatically or intravenously 
remains in the blood, it can only antidote the poison in the blood and not that 
in the nerve-cells. These observers advise that the antitoxin be placed where 
the toxins are active — that is, that it be thrown into the cerebrum (intracere- 
bral injections). The skull is trephined or opened with a small drill, a blunt 
needle is passed to the depth of one and a half inches into the frontal lobe, and 
the serum is slowly injected. Abbe follows Kocher; uses a local anesthetic 
and bores a very small hole through the skull midway between the outer angle 
of the orbit and the middle of a line running across the head from one exter- 
nal auditory meatus to the other. The serum should be concentrated. One gram 
of dry antitoxin is dissolved in 5 c.c. of water, and this amount is the proper dose. 
The opposite frontal lobe should also be injected either at once or the next 
day. Even when serum has been injected into the cerebrum it should also 
be given subcutaneously. Abbe employed intracerebral injection in 5 severe 
cases and 3 of them recovered. He is a strong believer in the method (" Annals 
of Surgery," March, 1900). Moschcowitz has collected 38 cases so treated 
and claims that one-half of them recovered. Cerebral abscess followed in 1 case 
("Med. News," Oct. 13, 1900). Tuffier has reported a successful case in 
which he injected 10 c.c. of serum into each frontal lobe (" Gaz. heb. de Med. 
et Chir.," July 4, 1901). The method has of late been practically aban- 
doned in spite of the early favorable reports. 

The value of the tetanus antitoxin in acute tetanus is more than doubtful. 
Under its use the mortality from acute tetanus is said to fall from nearly 90 
per cent, to 75 per cent., but the figures above given do not sustain this con- 
tention. Neither do the figures indicate that the mortality in chronic tetanus 
has been greatly influenced by it. Kitasato has shown that injections of iodo- 
form render animals immune, and Sonnani has maintained that this drug 
placed in a wound prevents the disease. If antitoxin is not obtainable, give 
hypodermatic injections of iodoform, 3 to 5 grs. /. i. d. 

BacelWs treatment consists in the hypodermatic injection of carbolic acid, 
which is thought to grasp tetanus toxin and mitigate it or even make it inert. 
The dose is 15 n\ of a 3 per cent, solution every two hours. Favorable results 
are claimed for the plan. 

The hypodermatic injection of an emulsion of fresh brain-matter has been 
advocated on the ground that brain-matter and tetanus toxin have a mutual 
affinity (Krokiewicz). The results are not conclusive. 

* Boston Med. and Surg. Jour., Oct. 6, 1898. 



Tubercle 213 

Mathews reports cure in 2 cases following the very gradual introduction 
into a vein of a solution containing sodium chlorid, sodium citrate, sodium sul- 
phate, and chlorid of calcium ("Jour. Am. Med. Assoc," August 29, 1903). 
Cure of acute tetanus has followed the intraspinal injection of a solution of 
magnesium sulphate (seepage 105 1), Blake has reported such a case ("Jour, 
of Surgery. Gynecology, and Obstetrics." May. 1906). It has been shown that 
a solution of magnesium sulphate strongly stimulates inhibition (Meltzer). 

Murphy reports the cure of a case by spinal puncture and injection of 
morphin and eucain into the theca of the cord (" Jour. Am. Med. Assoc.,' ' 
August 13, 1904). 



XIII. SURGICAL TUBERCULOSIS. 

Tuberculosis is an infective disease due to the deposition and multipli- 
cation of tubercle bacilli in the tissues of the body. The term surgical tuber- 
culosis is applied to all of those numerous tuberculous lesions that demand 
surgical treatment. Such lesions may exist in different structures, are often 
strictly localized processes, and in many instances may be extirpated, drained, 
or sterilized. Tuberculosis is characterized either by the formation of tuber- 
cles or by widespread cellular proliferation (diffuse tubercle) or by fibrinous 
exudation which is very rich in cells. Tuberculous conditions tend to casea- 
tion, sclerosis, or ulceration. 

A tubercle is a non-vascular infective focus, appearing to the unaided 
vision as a semi-transparent gray or yellowish mass the size of a mustard-seed. 
The microscopic tubercle is the most characteristic .evidence of the disease. 
The microscope shows that a gray tubercle consists of a number of cell-clusters, 
each cluster constituting a primitive tubercle. A typical primitive tubercle 
shows a center consisting of one or of several polynucleated giant-cells sur- 
rounded by a zone of epithelioid cells which are surrounded by an area of 
lymphocytes. When the bacillus obtains a lodgment the fixed connective- 
tissue cells multiply by karyokinesis, forming a 
mass of nucleated polygonal or round cells. These 

cells are connective-tissue cells and derived par- '?'^j?-:?^?/.«i ? «WfS^' 
ticularlv from endothelium and are called epithe- s=-^^*^'^^si^.*£-t& 
lioid cells from their resemblance to epithelial cells. 
Early in the development of a tubercle blood chan- 
nels lined with epithelioid cells exist, but continued 
cell proliferation blocks the channels and at the 
same time the blood-supply of the growth is fur- 
ther limited by the pressure of proliferating peri- 
vascular cells and the proliferation of the endothe- 
lial cells of adjacent vessels. Some of the epithe- 
lioid cells proliferate, and others attempt to, but 
fail for want of blood-supply. Those which fail to 
multiply succeed only in dividing their nuclei and 
enormouslv increasing their bulk (siiant-cells). Fi s 89- Synovial membr 

- - , , showing giant-cells (Bowlby). 

Giant-cells, which may also form by a coalescence 

of epithelioid cells, are not always present. Giant-cells are not certain evi- 
dence of tuberculosis for they occur in syphilitic lesions. The presence 








214 Surgical Tuberculosis 

of irritant bacterial products induces surrounding inflammation and numbers 
of leukocytes gather about the epithelioid cells (Fig. 89). 

The bacilli, when found, exist in and about the epithelioid cells, and some- 
times in the giant-cells. When bacilli enter the tissues they are often killed. 
If they enter in large numbers or are peculiarly virulent they induce chronic 
inflammation, granulation tissue forms, and the cells of the focus often have 
the characteristic arrangement described above. The bacilli are not pyogenic 
and suppuration means secondary infection. A tuberculous focus tends 
strongly to degenerative changes because of the local anemia and the pres- 
ence of bacilli. If numerous active bacilli are present caseation takes place. 
This is coagulation necrosis due to the action of bacteria upon a non-vascular 
area. It starts at the center of a tuberculous focus and spreads toward the 
periphery and finally forms masses like cheese. When caseated material is 
mixed with serum tuberculous pus is formed. 

A caseated focus may be surrounded or encapsuled by fibrous tissue. 
When this happens the tuberculous process may remain latent for months 
or years, perhaps awakening into activity as the result of a traumatism or 
lowered general resistance. A caseated focus may be cured by growth of fibrous 
tissue which replaces the tuberculous focus. This is cure by sclerosis. A 
caseated area may calcify. Even when tuberculous pus forms encapsulation 
may occur, the fluid being absorbed, and the remains being surrounded by 
fibrous tissue. Whenever tubercle bacilli consume all available food they die or 
remain latent. If they die the granulations are converted into fibrous tissue and 
the part is healed. If they remain latent they may at any time become again 
active. Infiltrated tubercle is due to the running together of many minute 
infective foci, or to widespread infiltration without any formation of foci. 
Infiltrated tubercle tends strongly to caseate. The description of a tubercle 
previously given relates to the common reticulated tubercle. Two other 
varieties exist. 

The fibrous tubercle is much richer in dense connective tissue than is the 
ordinary tubercle. It forms when bacilli are greatly weakened or killed. 
When this happens embryonal cells cease to degenerate, and ordinary inflam- 
mation results in fibrous tissue formation. Fibrous tubercle is evidence of 
an effort at cure. 

Hyaline tubercle results from hyaline degeneration of the reticulum of an 
ordinary tubercle and is the early stage of coagulation necrosis. 

The Incidence of Tuberculosis.— Tuberculosis is the most wide- 
spread of diseases, being particularly common in northern countries, in 
civilized regions, and in great cities. Both men and domestic animals suffer 
from it, and it is occasionally met with in captive wild animals. It may 
even occur in cold-blooded animals. It is rare in savage races and extremely 
rare in wild animals dwelling under natural conditions. 

How many persons die of tuberculosis is a much debated point. Some 
writers claim that consumption of the lungs alone kills one-third of all that 
die; and if the deaths from various other tuberculous lesions are added to 
this, it will be seen what an enormous part the disease plays in the mortality 
tables. Many observers hold that one-third of the human race suffer with 
tuberculosis, and that in every country the remaining two-thirds free from 
the disease are every moment in danger of acquiring it. Evans has main- 



The Bacillus of Tuberculosis 215 

tained that of the 35,000,000 deaths that occur yearly in the world, 5,000,000 
are the result of tuberculosis. Pfliigge thinks that one-seventh of the race 
die of tuberculosis. 

This enormous incidence of the disease, however, is disputed by some 
authorities; notably, by G. Cornet (Nothnagel's "Encyclopedia of Practical 
Medicine "). This distinguished observer states that one-seventh of all deaths 
result from tuberculosis, and that some pathologists have reported that in 
one-third of all necropsies tuberculous lesions are found; but that these sta- 
tistics are obtained from institutions where only the very poor are cared for, 
and that the percentage of tuberculosis is vastly lower in the better classes of 
the community. The exact figures, however, are hard to determine. It is 
certain that enormous numbers of people are affected with tuberculosis. 
I believe many affected ones recover, for Naegeli points out that almost all who 
perish after thirty from non-tuberculous conditions show healed lesions of 
tubercle. Von Behring maintains that all of us are "a little tuberculous" 
(Jonathan Wright, in "New York Med. Jour.," April 2, 1904). Pfliigge 
maintains that from 50 to 70 per cent, of the human race are predisposed 
to tuberculous infection and if infected would die of it unless an intercur- 
rent malady destroyed them. 

The Bacillus of Tuberculosis. — The tubercle bacillus was discovered 
by Robert Koch in 1882. It is a little rod with a length about equal to one- 
half the diameter of a red corpuscle. It does not form spores. Tubercle 
bacilli exist in all active lesions and the more active the process the greater 
their numbers. They may be widely distributed throughout the body, and 
are occasionally, though very seldom, identified in the blood. They may 
not be found in a tuberculous area, having once existed but died out for 
want of nourishment. For instance, in a cold abscess they are frequently 
absent. Bacilli may be destroyed by a secondary infection, for example, by 
a pyogenic infection. Even when present tubercle bacilli may be overlooked. 
Differential staining may exhibit the bacilli. In the material from an active 
tuberculous lesion, even if bacilli are not found, injection of the tuberculous 
matter into a guinea-pig will be followed by the production of the disease and 
in these lesions bacilli can be demonstrated. We have discussed the tubercle 
bacillus on page 46. The bacillus of leprosy, the smegma bacillus, and the 
tubercle bacillus are similar, but not identical. Each is an acid-fast bacillus; 
that is, if stained with an anilin color, mineral acids will not wash out the 
stain. All acid-fast bacilli are capable of producing lesions that, to some 
extent at least, resemble tuberculous lesions; but the lesions produced by all 
except the tubercle bacillus and the leprosy bacillus tend to cure. It is possi- 
ble that all acid-fast bacilli are branches from a common stem. 

The tubercle bacilli obtained from different animals differ considerably, 
both in morphology and in virulence. Koch has maintained that the bacilli 
of human tuberculosis differ radically from those of bovine tuberculosis, 
that human tuberculosis cannot be given to cattle at all, and that 
it is so difficult to transfer bovine tuberculosis to the human being that 
the danger from infected cattle is utterly trivial and may be disregarded. 
Ravenel and others have positively opposed this view of Koch's and there 
have been reported what appear to be undoubted cases of the transference of 
tuberculosis from animals to man. There is still dispute upon this point; 



2i 6 Surgical Tuberculosis 

but most writers believe that bovine tuberculosis and human tuberculosis 
are essentially the same, although the bacilli present temporary differences 
due to altered environment. The bacilli of bovine tuberculosis are certainly 
less dangerous to man than are the bacilli of human tuberculosis, and the 
bacilli of human tuberculosis are less dangerous to cattle than are the bacilli 
of bovine tuberculosis. 

Nocard reports 2 cases of individuals who wounded themselves while 
cutting the meat of tuberculous cattle. Both developed generalized lesions 
and died. Ravenel strongly opposes the view of Koch and maintains that 
the bacillus of bovine tuberculosis is highly pathogenic for man ("University 
of Penn. Med. Bull," xiv, 238, 1901). The same author reports 2 cases of 
tuberculosis of the human skin due to inoculation with bovine bacilli ('"Phila. 
Med. Jour.," July 21, 1900). 

Distribution of the Bacilli. — These bacilli are parasites, and not sapro- 
phytes; and the real, and only, source of infection is a tuberculous person 
or animal. Wherever there are tuberculous men or animals, the bacilli get 
into the air. The number that get into the air depends upon the number 
of animals affected, the seat of the tuberculous lesion in each, the care taken 
by the victims, and the control exercised by the community. 

The tubercle bacilli from an infected individual may get into the atmos- 
phere from the urine, the sputum, the feces, the sweat, the milk, or caseous 
or purulent material. The bacilli from dried sputum enter the dust, in which, 
fortunately, they are usually destroyed quickly by the complete dryness, the 
oxygen of the air, and the sunlight; but under some circumstances they may 
retain their virulence for weeks or even for months. The infected area itself 
is usually the direct source of the bacteria from a given case of tuberculosis, 
but this is not invariably so; for a tuberculous woman with a healthy mammary 
gland may secrete milk containing tubercle bacilli, a consumptive free from 
genito-urinary tuberculosis may occasionally pass urine containing bacteria, a 
cow may give tuberculous milk when the udder is not diseased, and tubercle 
bacilli may enter the bile of a tuberculous patient. It is probable that flies and 
insects may transmit infection (Lord, in "Boston Med. and Surg. Jour.," 
1904, cli); and it is sure that putrefaction does not certainly destroy the 
tubercle bacilli. This is proved by the fact that living bacilli may be passed in 
the feces of an animal that has been fed on tuberculous meat, and that they 
may be found in the feces of an individual suffering with intestinal tuberculosis. 
We are thus justified in concluding that slaughter-house waste, if improperly 
disposed of, is a danger to the community. 

Routes of Infection. — An individual may acquire tuberculosis by inhaling 
tuberculous material {inhalation tuberculosis), by swallowing tuberculous 
material {ingestion tuberculosis), and by inoculation with tuberculous material 
{inoculation tuberculosis). Infection of the lungs is commonly brought about 
by the inhalation of dried tuberculous sputum, or dust carrying tubercle bacilli. 
Ingestion tuberculosis may follow the eating of tuberculous meat, the drinking 
of tuberculous milk, or the consumption of uncooked articles on which tubercle 
bacilli have gathered. It has been shown that the lacteals may take up tubercle 
bacilli from the intestine, even if there is no intestinal lesion; and that bacilli can 
pass through the thoracic duct and into the blood, and lodge in some tissue, 
particularly the pulmonary tissue, so inducing tuberculosis. They tend to 



Routes of Infection 217 

lodge at any point of least resistance; and if not caught up in the lungs, will 
tend to be arrested in some other region that has been the seat of a trifling 
injury, — for instance, in an epiphysis that has been strained. It is a peculiar 
fact that a trivial injury constitutes a point of least resistance; but a severe in- 
jury, such as a fracture of a bone, does not do so. Baumgarten was a strong 
believer in the idea that bacilli enter the organism with the food and von 
Behring now warmly advocates the same view, teaching that bacilli enter the 
organism of every person in early life. They may be destroyed by tissue re- 
sistance, but if not destroyed have a period of latency and finally, perhaps 
after years, become active and cause the disease ("Deutsche Med. Woch.," 
Sept. 24, 1903). 

It is certain that inoculation may be followed by tuberculosis. The inocu- 
lation of tubercle bacilli in the intestine produces intestinal ulceration. It has 
been shown experimentally that rubbing the bacilli into the nasal mucous mem- 
brane may produce a local area of disease. Inoculation of the skin may result 
from a wound, the bacilli being carried into the wound itself. The usual 
victims of cutaneous inoculation are butchers, physicians making post-mortem 
examinations, and workmen that handle hides. In these cases, as a rule, an 
ulcer promptly forms at the point of inoculation; but in some few cases, the 
wound heals soundly, and tuberculous lesions develop in its neighborhood. 
In still rarer instances, no apparent inflammation or ulceration occurs in or 
around the seat of inoculation; but the anatomically related lymph-glands be- 
come tuberculous. 

A number of cases of inoculation tuberculosis have been reported. I 
myself have had one, in a physician, who inoculated his finger while making 
culture studies with tuberculous material. In this case, the axillary glands be- 
came tuberculous. I have also seen a tuberculous ulcer of the forearm in an 
attendant of a lunatic asylum, who had been bitten by a tuberculous patient. 
Inoculation tuberculosis occasionally follows circumcision, as practiced by an 
orthodox rabbi, the operator having been tuberculous. There have been re- 
ported apparent cases of direct inoculation of the genito-urinary tract during 
sexual intercourse. If there has been some definite injury of the tissues, in- 
oculation may follow a simple rubbing of tubercle bacilli into a part. 

When the mother's ovum is tuberculous, the disease may be directly trans- 
mitted to the fetus, producing the condition known as congenital tuberculosis; 
and it seems possible that tuberculous sperm-cells may be responsible for the 
same condition. Baumgarten believes that bacilli may pass the placenta, 
enter the fetus, and remain lateral for years. Latent bacilli have been found 
in normal lymph-nodes (Harbitz, in "Jour. Infect. Diseases," vol. ii, 1904); 
this proves that latency is possible. The direct transmission of the disease, 
however, is unusual, but the transmission of a hereditary predisposition to 
infection is not unusual. In some cases of tuberculosis we can satisfy our- 
selves clinically as to the cause of the infection. For instance, when an in- 
dividual is injured with an object known to carry tubercle bacilli, if an ulcer 
of the skin forms, and the adjacent lymphatic glands enlarge, the deduction is 
obvious. In other cases, it is impossible to make up our minds as to the cause 
of a tuberculous lesion. For instance, we can only guess that a person has 
inhaled tuberculous material or has eaten tuberculous food. If in inoculation 
tuberculosis no lesion arises at the point of entry, the opinion as to the causa- 
tion will be founded merely upon guess-work. 



2i 8 Surgical Tuberculosis 

It seems sure that when the bacilli of tuberculosis enter into the body, if 
they are not destroyed by the body-resistance, they either produce a local 
lesion at the site of inoculation, or pass to the nearest lymphatic glands, and 
there establish disease. The first lesion is known as the primary focus, and 
from this focus the disease may be disseminated to the most distant parts. 
The bacilli enter readily, if there is a wound or an abrasion; but in exceptional 
circumstances, they may enter through unbroken skin and undamaged mucous 
membrane. Any structure may become tuberculous, but some structures 
are much more liable to do so than are others. The lungs are very liable; 
the conjunctiva is very resistant. 

It is seldom that infection is disseminated by the blood-stream; as a rule, 
it is effected by the lymph. Dissemination by the blood-stream means rapidly 
advancing and widespread tuberculosis; dissemination by the lymph-stream 
means slowly advancing tuberculosis, with localization of lesions. In dis- 
semination by the lymph-stream, the dissemination is usually in the normal 
direction of the lymph-current; but if the lymph-vessels become blocked, 
lymph-regurgitation may occur, and then the dissemination is in a direction 
opposite to the normal flow of the lymph-current. 

Products of the Tubercle Bacilli. — A great variety of products are 
formed by the tubercle bacillus, and among them we may mention alkaloids, 
toxalbumins, fatty acids, and ferments. Experimental injection of the toxal- 
bumins produces inflammation; and of the alkaloids, fever. It has been shown 
by Maragliano that injection of the toxalbumins actually lowers the tempera- 
ture. Beyond any doubt, the culture-material in which tubercle bacilli grow 
contains poison; and the bodies of the bacilli themselves contain poison. The 
poisons in the culture-medium are called extracellular poisons, and those 
within the bacilli are called intracellular poisons. It is quite probable that the 
former poisons are the same as the latter, and have merely passed from the 
bacilli into the culture-medium. 

Tuberculin. — It was proved some time ago that dead bacilli are toxic 
and, if experimentally injected, induce a toxic condition in the animal, cause 
inflammation of the kidneys, and sometimes produce cold abscess subsequently 
at the seat of injection. Koch collected the poison from dead bacteria in the 
form of a liquid, which he called tuberculin. A number of different methods 
of extracting such poison have been suggested; hence, there are a number of 
different tuberculins. Koch has made several himself. His early tuberculin 
was a glycerin extract of a culture of tubercle bacilli; his later tuberculin is 
made from the dried bacilli, ground up, and mixed with water, the fluid being 
centrifuged. When centrifuged, two layers separate. The upper layer is 
the old tuberculin, and the lower layer is the new tuberculin. Koch calls this 
new tuberculin tuberculin oberst (Tuberculin O.). 

It was discovered by Koch that tuberculous animals are much more strongly 
affected by an injection of tuberculin than are healthy animals. The most 
positive reaction is noted in the tuberculous area; but, as a rule, there is also 
a reaction in the area where the injection is made. We get no reaction from 
the administration of tuberculin by the stomach, but occasionally can obtain 
it by the inhalation of the dried material. If a moderate dose of tuberculin 
is injected into a non-tuberculous animal, there may be a trivial redness at the 
point of injection and a slight and temporary rise of temperature; or there 



Products of the Tubercle Bacilli 



219 



may be no evidence of reaction whatever. An injection in a tuberculous ani- 
mal, however, is followed by distinct inflammation at the seat of injection, and 
a positive reaction in the tuberculous area. This area undergoes congestion 
or inflammation, leukocytes collect around it, and the part tends to necrosis, 
and is liable to break down. 

In addition to the changes already mentioned, there is elevation of tempera- 
ture. If the dose has been small, there may be only a slight feeling of coldness 
to usher it in; but if the dose has been large, there is usually a distinct chill. 
This chill comes on eight to twelve hours after the injection and is accompanied 
and followed by elevated temperature. The fever lasts from four to twenty- 
fours hours, and the temperature is elevated to from two to five degrees 
Fahrenheit. The febrile condition is accompanied with pain in the head, 
limbs, and back, and with increased rapidity of the circulation, restlessness, 
weakness, and usually nausea. As the temperature passes to normal all the 
symptoms disappear. The slight elevation of temperature when tuberculin 
is injected into a non-tuberculous animal is not ushered in by a chill, and 
does not exceed one degree Fahrenheit, unless a very large dose is given. 
We thus note that the injection of tuberculin may be of the greatest possible 
value in diagnosis. 

A good many observers have grown fearful of injecting tuberculin, believ- 
ing that it is liable to cause the tuberculous focus to spread, or actually to 
lead to the development of disseminated tuberculosis. Yirchow was of this 
opinion. That such a condition may follow the use of large doses seems cer- 
tain, but moderate or small doses appear to be entirely safe. Flick has pointed 
out that if a blister is applied to a tuberculous person a distinct febrile reaction 
appears a number of hours after the application. This is due to the absorption 
of toxic material, probably tuberculin, from the blister. It is known that in a 
tuberculous animal certain excretions (urine) and serous exudates contain 
tuberculin. Merieux and Baillon show that if a tuberculous person is blistered 
the fluid of the blister, injected into a tuberculous animal, produces a definite 
reaction. This proceeding is of diagnostic value. The tuberculin comes 
from the tuberculous person and he is proved to be tuberculous by injecting 
the tuberculin into another tuberculous animal. 

Professor Behring (Paris Congress of Tuberculosis, Oct., 1905) main- 
tains that there is a curative principle not identical with antitoxin. He ob- 
tains a substance from tuberculous material, which he calls T. C. and he in- 
troduces this substance into the living body. When T. C. is acted on by the 
cells of the living body, it is altered; and the hypothetical material, T. X., is 
formed. This distinguished laboratory worker says that the T. C. is the 
vital principle; and that when cattle are immunized by inoculating attenuated 
bacilli, the T. C, by acting on the body-cells, is responsible for the diagnostic 
reaction to tuberculin and for the protective action towards tuberculosis. 
Some try by means of supposed antitoxins to immunize the body-fluids, but 
he tries instead to immunize the body-cells. He is unwilling to inject living 
tubercle bacilli into human beings; so he frees the tubercle bacilli of certain 
substances, leaving an organism that resembles the tubercle bacillus, which he 
calls the rest bacillus. This rest bacillus is, by certain methods, converted 
into an amorphous material identical with the T. C. formed by the action of 



220 Surgical Tuberculosis 

the body-cells upon the virus. This T. C. is taken up by lymph-cells; and 
it so changes these cells that they are converted into eosinophiles or oxy- 
philes, and the change in these cells makes the body immune. T. C. may 
safely be injected, as it is not a living material; and, whereas it may produce 
tubercles, they do not tend to caseate. Professor Behring believes that this 
material may be used in the treatment of human tuberculosis. 

Resistance of Bacilli. — Among the antagonistic elements, we have 
mentioned oxygen, dryness, and sunlight. Moist heat, at the temperature of 
boiling water, is rapidly fatal. A 5 per cent, solution of carbolic acid is one 
of the most powerful of germicides. Full-strength alcohol is next in point 
of power. Corrosive sublimate is not a satisfactory germicide. Formalde- 
hyde is fatal only after long exposure. Iodoform and ether is a reasonably 
powerful mixture. 

That the virulence of tubercle bacilli varies under different circumstances 
is sure. Under some circumstances they may be extremely powerful; under 
others nearly innocuous. The liability to infection depends, perhaps, in 
part, on individual predisposition, and certainly, to a great extent, on the num- 
ber and the virulence of the bacteria. 

Immunity. — It seems likely that some persons are immune to tuberculo- 
sis — persons coming from an ancestral line in which all the predisposed have 
died off, so that the immediate ancestors of the line were non-susceptible. 
The tendency to immunity may be strengthened by proper marriages, and 
may be weakened by improper marriages; or immunity in a line may be de- 
stroyed by the continuance of unfavorable conditions. Of course, the term 
immunity is only relative. No one can be absolutely immune; for when 
subjected to extremely unfavorable circumstances, or when a number of viru- 
lent bacilli are introduced, anyone may become tuberculous. 

Predisposition. — Personally, I believe that there is such a thing as 
a predisposition towards tuberculosis; just as there is towards many other 
diseases. Such a predisposed individual has temporarily or permanently 
acquired a condition of the body-cells, body-fluids, or both, that either makes 
easy the entrance of the bacilli, or prevents strong opposition to their multipli- 
cation when they have entered. A person is predisposed when the opsonic 
index is low, for this indicates lack of phagocytic power in the leukocytes. 
Predisposition may be increased by some extraneous circumstance, such as oc- 
cupation, residence, etc., that brings the individual into frequent or pro- 
longed contact with virulent bacteria. 

There is certainly such a thing as congenital tuberculosis, although it is 
unusual; and any tissue may be involved in the congenital trouble. Young 
children are very liable to tuberculosis of the acquired form. According to 
Professor Behring, many children become infected with tuberculosis in their 
early years by eating tuberculous food; but such a tuberculosis often remains 
latent for a considerable length of time, and then develops. This theory ob- 
tains probability from the fact that the digestive organs of the child are not 
strongly protective against bacteria as are those of the adult. 

A question is, Do certain individuals possess a special predisposition to 
develop tuberculosis, and is this hereditary? Hereditary predisposition was 
once regarded as practically the only cause of the disease, but many thinkers 
now regard* it as of slight importance; although I do not see how we can deny 



Predisposition 221 

its existence. We all see how common is tuberculosis in the descendants of 
tuberculous persons. Hutley studied 432 cases of tuberculosis. In 23.8 
per cent, one or both parents had the disease (the father alone in 11.5 per 
cent., the mother alone in 9.9 per cent., and both in 2.4 per cent.). Some 
maintain that in 30 percent, of consumptives, one parent or both parents have 
been consumptives; and in 60 per cent, a parent or a grandparent has suffered 
with tuberculosis. Because of the extreme frequency of the disease, however, 
this statement does not prove that the cases in the family are due to heredity; 
but that there must be such a thing as hereditary predisposition is indicated 
by the fact that there are many families living under similar conditions to the 
tuberculous families, without there having occurred, through several genera- 
tions, a single case of tuberculosis among their members. A feature that makes 
us unable to reach a certain conclusion is that tuberculosis is contagious; 
and several members of a family may be infected from one member, even 
when there is no predisposition to the trouble by heredity. The mere living 
in one house may account for the infection. A fact strongly in favor of the 
hereditary influence is that in a family whose ancestors have been tuberculous 
and whose members have not lived together, but have been scattered widely 
over the earth, member after member may die of the disease. 

Unhealthy environment particularly predisposes to tuberculosis; and 
the element of poverty — leading, as it does, to taking improper or insufficient 
food, dwelling in an unhygienic room or in an overcrowded building, pursuing 
an exhausting occupation, working for long hours, and obtaining insufficient 
amusement and outdoor exercise — also has a most powerful unfavorable 
effect. As a class, the poor dislike ventilation, take insufficient exercise in 
the open air, do not get enough sunlight, work in a dusty atmosphere, eat im- 
proper food, and not enough of it, live in damp and dirty rooms, and many of 
them drink quantities of whiskey. City life is a predisposing cause of tubercu- 
losis, for many of the foregoing reasons, and particularly because many city 
workers follow an indoor occupation. The enemies of tuberculosis are sun- 
light, fresh air, nourishing food, and outdoor exercise; and the limiting of 
any of these factors favors the development of the disease. 

Tuberculosis may occur in any region that man inhabits; although in 
some regions it is rare, and in others it is excessively common. Its great fre- 
quency in some regions is probably due less to climate than to environment, 
occupation, and heredity; and the greatest predisposition is found in the town 
dweller. There is much more tuberculosis among males than among females. 

An injury may be followed by the development of tuberculosis at the seat 
of injury, the injury creating a point of least resistance in which bacilli may 
lodge. A slight injury of a joint or a bone is the most common traumatic 
predisposition; although a chest injury may be followed by tuberculous 
pleuritis, and a head injury by tuberculous meningitis. The injury that pre- 
disposes, as previously stated, is a trivial, and not a severe one. In some cases 
in which tuberculosis develops after injury, the injury has been a mere coinci- 
dence; in others, a region the seat of an undeveloped tuberculosis has been 
affected by the injury, and the tuberculous process has thus been awakened into 
activity. If there is no tuberculous focus at the seat of injury, we are justified 
in concluding, when tuberculosis develops, that a point of least resistance has 
been created. Such points are more common in those that have a focus of 



222 Surgical Tuberculosis 

tuberculosis somewhere about the body, but may apparently occur in those 
that have no such focus. Many diseases and conditions predispose to tuber- 
culosis. Tuberculosis is very common in chronic drunkards, in the insane, 
and in the sufferers from tertiary syphilis, diabetes, and Bright's disease. 
Any exhausting malady may be followed by tuberculosis. 

The Term Scrofula. — Many surgeons positively oppose the use of the term 
scrofula, but I believe that there is clinical value in retaining it. The surgeons 
that have entirely abandoned it think that, after all, it is exactly synonymous 
with tuberculosis. I use it to designate the persons that are predisposed to 
tuberculosis through possessing a type of tissue of low resisting power. These 
tissues fall a ready prey to the bacteria of tuberculosis. Such tissue-vulner- 
ability is usually hereditary; and, as a rule, one, or even both parents are 
tuberculous, are in ill health, or are themselves predisposed. Occasionally 
this type of tissue is acquired, a child having at first been apparently entirely 
healthy; and later, owing to poor food, insufficient air, and bad hygienic 
surroundings, developing scrofula. 

That scrofula is not simply osseous, articular, or glandular tuberculosis is 
proved by the fact that a person that we recognize as scrofulous may never 
throughout his life develop a tuberculous lesion. Some surgeons think that 
scrofula is latent tuberculosis, and will, under the influence of some exciting 
cause, burst into activity. This is possible, but unproved. We do know 
that some so-called scrofulous lesions are not tuberculous ; for instance, facial 
eczema, corneal ulceration, granular lids, and mucous catarrh. These 
lesions are rather expressive of poor health, improper food, and deprivation of 
fresh air. 

The subjects of scrofula, besides being prone to the non-tuberculous lesions 
above mentioned, are particularly prone to develop tuberculous lesions; and 
such a lesion may arise in any part that has been the seat of a slight injury or 
of a non-tuberculous inflammation. The parts most apt to become tubercu- 
lous are the bones, the joints, and the glands. 

There are two types of the so-called scrofulous, that is, two types of those 
that are predisposed. The common type is known as the phlegmatic, or 
lymphatic; and it is this type that is particularly described by our surgical 
forefathers. In the phlegmatic type, the individual is stolid of expression; 
and has thick, coarse skin, a muddy complexion, dark, coarse hair, a thick 
neck, thick lips, a thick nose, and a heavy lumbering gait. He is dull of 
apprehension, with feeble emotional reaction, and but little capacity for con- 
centration or interest. The other type is much more seldom met with. It is 
what is called the sanguine type, or what the elder Gross spoke of as the an- 
gelic type. Such a child is frequently beautiful, and graceful in its movements. 
Its skin is transparent and clear, and the color comes and goes. The eyes 
are blue, the lashes long, and the hair silky. The tendency is to thinness, 
rather than fat; and the mind is not dull, but precocious and the temperament 
is nervous. In both these types of scrofula, the condition of lymphatism exists. 

Lymphatism, or the Lymphatic Constitution (Status Lymphati= 
CUS). — This term was introduced by Potain to designate a condition in child- 
hood in which there is a very strong disposition to the development of disease 
of the lymphatic structures, or in which at birth there was excessive develop- 
ment of these structures. The enlarged glands may be tuberculous from 



The Diagnosis of Tuberculosis 223 

the beginning; but, as a rule, they are not so in the beginning, but tend to 
become so. Inflammation of a mucous membrane is followed by enlarge- 
ment of the anatomically related lymphatic glands. These enlarged glands 
are frequently met with in the neck. We find them associated with enlarged 
tonsils and pharyngeal adenoids. 

Usually lymphatism is congenital, but it may be acquired when children 
are placed under unfavorable conditions. Lymphatic children frequently 
have rickets and are invariably anemic. In infancy, it is the bronchial and 
mesenteric glands that are particularly apt to enlarge; in childhood, it is the 
glands of the neck. In lymphatic children, it is not uncommon to have a per- 
sistent thymus gland. In some cases a goitre appears. As the child increases 
in age, the lymphatic enlargements are likely to disappear, unless tuberculous 
infection has occurred. After a child has reached the age of seven or eight 
years, non-tuberculous glands of "the neck cease to enlarge; and by the time 
of puberty, they have usually disappeared. 

If an operation is performed on the victim of lymphatism the wound is 
very liable to become infected; and the bleeding from the wound is very trivial. 
The victims of lymphatism are more apt than other persons to die under a 
general anesthetic, and occasionally one of them dies during natural sleep. 
(See* Dr. Geo. Blumer, in the " Bulletin of the Johns Hopkins Hospital," 
Oct., 1903.) 

The Diagnosis of Tuberculosis.— Whenever he sees a persistent 
area of chronic inflammation in any structure of the body the surgeon must 
think of the possibility of its being tuberculous. A thorough investigation 
must be made into the local disease and the body generally; and of particular 
importance is it to determine whether there is any other diseased locality, and 
whether there is any evidence of tuberculous disease anywhere in the body. 
The patient's history must be investigated, and any possible tendencies or 
predispositions inquired into. 

In many cases of tuberculosis, the diagnosis can be made from purely 
clinical investigation. This is the case, for instance, in many tuberculous 
ulcers, abscesses, and glands. In some cases the diagnosis can be made only 
by making differential stains of material obtained from the suspected focus, 
or by removing a section of the inflammatory area with a Mixter's cannula, 
and studying it carefully under the microscope. Cultures may be taken from 
any material obtained from the suspected focus. 

In doubtful cases, animal inoculation is necessary to make a diagnosis. 
The material is injected into a guinea-pig; and if it be tuberculous, the animal 
will develop miliary tuberculosis within a few weeks. With apparently sterile 
fluid obtained from a tuberculous focus, the disease can be induced in guinea- 
pigs by inoculation. Blistering a tuberculous person causes elevated tempera- 
ture (page 2 1 g). If the fluid of the blister be injected into a tuberculous 
animal a distinct reaction occurs (page 219). 

In a suspected case of tuberculous meningitis of the brain or of tuberculous 
disease of the membranes of the cord, the theca of the cord should be tapped 
(lumbar puncture), and the fluid obtained should be carefully examined. Of 
course, if, in a case of tuberculous cerebral meningitis, the foramina in the floor 
of the fourth ventricle have been blocked by exudate, no characteristic fluid 
will be obtained by tapping. It is usually found, however, that even in tuber- 



224 Surgical Tuberculosis 

culous cerebral meningitis, there is increased tension of the fluid in the sub- 
arachnoid space of the cord, that this fluid is present in unnaturally large quan- 
tity, and that it is turbid through the presence of pus and white blood-cells. 
Sometimes it contains bits of fibrin, and sometimes blood; and in many cases, 
the bacilli of tuberculosis. Exploratory abdominal incision is sometimes nec- 
essary to determine the existence of tuberculous peritonitis. 

The ac-rays are of great aid in making a diagnosis of osseous, articular, and 
perhaps certain forms of pulmonary tuberculosis. The area of tuberculosis 
is lighter than the surrounding healthy structures when seen by the #-rays. 

The tuberculin test may sometimes be used to very great advantage. We 
have already said that if given in moderate doses, it is safe; that is, it is safe 
if the disease is not too far advanced. Very large doses, or the giving of the 
remedy at all in greatly advanced tuberculosis, would not be safe. When we 
wish to make a diagnosis by means of tuberculin, we give a dose of i mg. of 
the fluid hypodermatically. If no reaction occurs within twenty-four hours, a 
dose of 2 mg. is given. If there is no reaction from this dose, the surgeon 
waits another twenty-four hours, and gives a dose of 3 mg., and he so keeps on, 
advancing the dose until he reaches the amount of 8 or 10 mg. Ten mg., how- 
ever, is the maximum dose for diagnostic purposes. If after the administration 
of one of these doses a reaction is obtained, no further administration of the 
drug is, of course, desirable. 

It is the advice of Dr. Norman Bridge that distilled water be added to the 
tuberculin until the tuberculin-strength is 10 per cent. This water should 
contain 2 per cent, of carbolic acid. When ready to administer the material 
the fluid is made into a 1 per cent, solution by diluting with distilled water. 
The 1 per cent, solution, as Dr. Bridge says, represents a milligram of tuber- 
culin to a minim and a half of fluid. 

Tuberculin is not to be given for diagnostic purposes unless the tempera- 
ture of the patient is normal or very nearly normal; and, as Dr. Bridge points 
out, when we make the tuberculin test, the temperature should be taken every 
two hours for twenty-four hours before the test and at like intervals for a like 
length of time after, in order to know thoroughly the effect that has been pro- 
duced. 

We have previously described the tuberculin reaction; that is, the local 
congestion or inflammation in the tuberculous area, and the chilly sensation 
or chill, followed by marked elevation of temperature. In certain tuberculous 
lesions we can see the local reaction; for instance, in lupus. In joint tubercu- 
losis the skin over the joint becomes red. In a tuberculous ulcer of the mouth 
we can see the changes; and in a lesion of the larynx the laryngologist can 
observe them with the laryngoscope. By means of a cystoscope the local re- 
action can be seen in a tuberculous ulcer of the bladder. 

Not only should this test not be used in advanced pulmonary tuberculosis 
because it is unsafe but it is also needless in any advanced case because the 
diagnosis is perfectly clear without it. We never should give extremely large 
doses in making. the tuberculin test, because an extremely large dose may 
obtain a positive Reaction even in a healthy man. A person with actinomy- 
cosis or secondary syphilis may show a reaction to tuberculin which confuses 
our results. If, after the careful use of tuberculin, there is no reaction, it is 
usually a safe conclusion that there is no tuberculosis. 



Treatment of Tuberculosis 225 

The agglutination test, as applied to the blood-serum of a tuberculous 
individual, is decidedly uncertain. It is very unusual to be able to find bacilli 
in the blood, though they may occasionally be found there in miliary tubercu- 
losis. 

Prognosis. — Many cases of tuberculosis are cured. This is indicated 
by the frequency with which we find healed tuberculous lesions in necropsies 
on individuals dead of other diseases. We reach the same conclusion from 
the clinical study of many cases. The prognosis of a single tuberculous focus, 
especially if it can be extirpated or sterilized, is very good; provided that the 
general health is good, that there is not much anemia, that the digestive 
processes are well performed, that mixed infection is absent, that there are no 
albuminoid changes in the viscera, and that the patient is able and willing to 
live the life that is necessary for his welfare. Of course, the prognosis is in- 
fluenced by the patient's temperament, his willingness to brook control, his 
monetary status, and his habits. The danger is greatly increased by multiple 
lesions. The dangers of mixed infection and of albuminoid disease have been 
previously discussed. 

In very young children the prognosis is most unfavorable; but in older 
children it is very much better; in fact, it is better in them than in adults. 

Tuberculosis of the skin gives a very fair prognosis ; and glandular, bony, 
and articular tuberculosis are frequently recovered from: but, of course, any 
tuberculous lesion, however limited in area, is a profound menace. 

Another fact to be borne in mind is that many cases apparently cured are 
not really cured; and that the disease strongly tends to reappear in the same 
region or in a nearby region, or to reappear later in another part of the body. 
We should, further, remember that in many cases in which there is apparently 
one lesion only, there are, in reality, distant lesions undiscoverable by 
clinical methods. In any case of tuberculosis the higher the opsonic index the 
better the prognosis, the lower the opsonic index the worse the prognosis 
(page 38). 

Another important fact is that when an individual has a latent focus of 
tuberculosis, especialy if this latent focus is in the lungs, should a surgical 
operation be performed for some other purpose, and the patient be kept in 
bed for a considerable length of time, the latent focus may become active. I 
have always believed that in latent pulmonary tuberculosis the administration 
of ether or chloroform might waken the disease into activity. It therefore 
becomes evident that in such persons operations of necessity are the only 
ones that should be undertaken. Such an operation, if possible, should be 
done under a local anesthetic; and the patient should be got about again at 
the earliest possible moment. 

Treatment. — One of the first thoughts of the surgeon is to provide against 
the contamination of healthy individuals by the infected. Any infected ex- 
cretion or suspicious discharge from the patient must be disinfected at once and 
dressings that are removed from the patient should be burned. 

We are not in this section discussing the treatment of tuberculosis of the 
lungs, which belongs to the medical man, and in which climate is of the first 
importance. In cases of surgical tuberculosis, however, the patient may do 
better in some climates than in others; and the change, by stimulating the 
appetite and causing him to sleep and giving him renewed hope, will be bene- 
15 



226 Surgical Tuberculosis 

ficial. In surgical tuberculosis, climate is not the factor that it is in tuberculo- 
sis of the lungs; but if there is pure atmosphere, an equable temperature, and 
plenty of sunlight, the climate will lure the patient out-of-doors, and will thus 
be greatly to his advantage. 

A life in the open air is the most essential thing in the treatment of surgical 
tuberculosis; but, as Professor Halsted points out, it is not of much use to tell a 
great many persons to live in the fresh air. They will not do it, unless they are 
made to; and it is hard to make them unless they live in quarters especially 
built with this object in view. Therefore, other things being equal, if the pa- 
tients with surgical tuberculosis have the means, it is a good plan to send them 
to a sanitarium in the mountains or at the seashore, where they can obtain the 
persistent, unbroken life in the open air that is the cure of the disease. The 
patient should spend his days in the fresh air, and he should sleep at night 
directly exposed to the air; and if the atmosphere is free from dust and foul 
odors, so much the better. The poorer patients must get the fresh air at home, 
if they cannot be sent to some camp or colony. In large cities adjacent to the 
seaside resorts, poor people can usually be sent for a short time, at least, to 
the seaside; and I am a very great believer in the beneficial effects of Atlantic 
City and other seashore resorts. 

It is frequently necessary to do an operation in a great city, although we 
operate much less than formerly for these conditions. If an operation is done 
in a great city, the patient is kept in the fresh air as much as possible during 
his convalescence. If it is feasible, he is sent away to a colony or sanitarium 
to recuperate. It would be an excellent thing if, in many of those cases in 
which operation is necessary, the operation could be performed at the camp or 
the sanitarium. One advantage of the camp or sanitarium is that the patient is 
watched and regulated daily, and is led to do things that otherwise he would ne- 
glect. Many patients endeavor to evade going out when they should, because 
they are afraid of taking cold; and many of them are just neglectful and do not 
want to take the trouble to do it. 

It cannot be too strongly insisted on that in surgical tuberculosis fresh air 
is of as much importance as in tuberculosis of the lungs. It increases the vital 
resistance, it stimulates opsonic power,, and it causes the patient to eat more 
nourishing food and to sleep better at night. Frequently we see children 
that have had sinuses for months get rapidly well when they adopt an open-air 
life; and, although albuminoid changes, when they once exist, will never pass 
away, further albuminoid changes may not take place if the patient lives 
properly. 

A patient with surgical tuberculosis can have no more injurious environ- 
ment than a dark, damp room, especially if it is in a crowded tenement and up 
a narrow court. The value of sunshine is also beginning to be appreciated. 
We know that it limits the growth of tubercle bacilli. It is not the heat that 
benefits the person, but the chemical rays of sunlight. These rays have some 
germicidal influence, have considerable penetrating power, and seem to influ- 
ence decidedly the nutritive processes. 

The area of tuberculosis requires rest. We have long known how disas- 
trous it is to confine a person to bed in a dark, ill-lighted, and improperly 
ventilated room. We can, however, confine a person to bed with perfect safety 
if there is a free flow of fresh air. We must confine certain cases to bed; for 



Treatment of Tuberculosis 227 

instance, cases of tuberculous peritonitis, and some cases of bone tuberculosis, 
and of joint tuberculosis. A patient with tuberculosis who has fever ought to 
be in bed. We can put such patients to bed without any fear of the disease 
becoming worse or spreading if the supply of fresh air is plentiful and if the 
patient is kept warmly covered and wears a skull-cap. Of course, a draft is to 
be avoided. Patients that are confined to bed do excellently in a tent, in a 
cottage sanitarium, or on a porch that has been altered for the purpose. 

At the very first possible moment the patient should be got out-of-doors; 
and in many cases of tuberculous disease (for instance, vertebral disease), 
the tuberculous part is supported by means of a brace or a splint. 

We thus see the two-fold nature of the modern treatment of surgical tuber- 
culosis: rest for the tuberculous part and a life in the open air. Exercise is 
of importance also, although it should never be taken in excess. If the patient 
is confined to bed, he should be massaged and rubbed with alcohol, the tuber- 
culous part being avoided. Manipulation must never be applied to a focus 
of tuberculosis because it may lead to dissemination. If a person has fever 
he must not attempt active exercise, but must be confined to bed. 

One should overfeed tuberculous patients, if the stomach tolerates it; 
but not on any single article, or even on any particular one. The diet should 
contain a sufficiency of fats, proteids, and carbohydrates; and the food should 
be agreeable to the taste and readily assimilable. Otherwise, disgust will be 
engendered; and with disgust comes indigestion and loss of appetite. The 
very life of the patient may depend on his remaining able to take a sufficiency 
of nourishing food. 

There is no specific diet for tuberculosis, although many have been sug- 
gested. One of the most valuable foods is milk, taken raw or mixed with 
other articles, such as lime water or sodium carbonate, and frequently with 
brandy. The use of an exclusive diet of boiled milk is to be deprecated, and in 
children it sometimes leads to the development of scurvy. Practically anyone 
can take milk, if proper efforts are made. 

Soft boiled eggs are useful; and bread or toast should be eaten with plenty 
of butter, which is an agreeable form of fat. Vegetables and fruits are desirable. 

If the patient can take cod-liver oil without impairing his appetite or di- 
gestion, it should be given; provided the weather is not too hot. Cod-liver 
oil produces diarrhea in very hot weather. Children learn to take it very well. 
To many adults, however, it is, and remains, absolutely abhorrent. The 
chief value of cod-liver oil is that it is a fat, and it seems improbable that it 
contains any elements specifically antagonistic to tubercle. If used, large 
doses should not be given; as they will not be digested. The common dose 
for an adult is a teaspoonful two or three hours after meals. Thirty drops three 
times a day is usually given a child, and an infant should receive 15 drops 
three times a day. 

There is no satisfactory specific treatment for tuberculosis, every suggested 
one having failed on a careful test. We do know that we can induce 
immunity in animals by the injection of attenuated living bacilli (Trudeau), 
but we cannot venture to endanger a man's life by making such attempts. 
As previously pointed out, von Behring believes that he is able to produce 
immunity in man; but in any case, producing immunity is a different thing 
from curing an existing disease. We no longer have high expectations of 



228 Surgical Tuberculosis 

tuberculin. It is never given in advanced cases or if there is secondary pyo- 
genic infection. Its use is limited by most practitioners to the treatment of 
lupus in which disease it is sometimes of value. When used it is given in small 
doses, far smaller than those given for diagnosis (page 224). Antitoxin obtained 
from a horse supposed to have been rendered immune is of doubtful value. 
We know of no drug or medicine that can with safety be used at the present 
time with any real hope that it will specifically destroy tubercle. Drugs are, 
of course, given; but they are of secondary importance. 

Tonics are used, and in children, the syrup of the iodid of iron has con- 
siderable reputation. Remedies may be needed to improve digestion, to con- 
trol night-sweats, etc. I do not believe that beech wood creasote or carbonate 
of guaiacol internally, or iodoform inunctions, or painting the surface with 
guaiacol confer any real benefit in tuberculosis. 

Alcohol is often required. It is not needed in all cases, but is in many. 
We should avoid it in children, however, unless there is a particular indication 
for its use. When a tuberculous patient is weak, milk-punch or egg-nog is 
of service; and in any case of mixed infection, alcohol is required in full doses. 
If fever exists, and the administration of alcohol makes the pulse more rapid 
and the delirium worse, and causes flushing of the face, the dose is too large 
and should be diminished. Any patient that smells strongly of alcohol is get- 
ting an overdose. 

The Local Treatment of Tuberculosis.— When certain drugs are directly 
inserted into a tuberculous focus, they do possess an antagonistic influence. 
Iodoform is the most powerful of these drugs; guaiacol, balsam of Peru 
(Landerer),and chlorid of zinc (Lannelongue) have a similar action. Iodo- 
form has little or no influence when placed on a free surface exposed to the 
air; but when in the form of an emulsion it is injected into a tuberculous area, 
the air being excluded (page 29), this drug is powerfully antituberculous. 
Chlorid of zinc seems to act by causing the development of quantities of 
fibrous tissue, which encapsulates, or perhaps replaces, the tuberculous focus. 
Some surgeons inject tuberculous nodules with camphorated naphthol. Every 
region of tuberculosis requires local rest, perhaps by the use of a splint or a 
brace. 

Special Methods of Surgical Treatment. — The surgeon may endeavor 
to extirpate a tuberculous focus, or to drain it thoroughly and to sterilize the 
area. Extirpation is sometimes, although not very frequently, possible. Com- 
plete extirpation is a valuable method, but partial extirpation is dangerous. 
If a part only of a tuberculous focus is extirpated, many lymph-tracts and blood- 
vessels are opened ; and the incomplete operation may lead to the dissemination 
of the disease. The methods of surgical treatment suited to different forms 
of tuberculous disease will be discussed in different sections of this book. 

Bier's Method by Congestive Hyperemia. — Bier believes that passive 
hyperemia is of the greatest possible benefit. Active hyperemia is obtained 
by heat, and is especially valuable to induce the absorption of the products of a 
non-tuberculous chronic inflammation. Passive hyperemia is particularly 
useful in tuberculosis and, if a limb is affected, is obtained by placing a rubber 
band around the limb above the part, the band being applied with sufficient 
firmness to interfere with venous return, but not so tightly as to block arterial 
entry. This band should be applied daily, and should be kept in place for 



Tuberculosis of the Skin 229 

an hour or so or several hours at a time. When the band is put on, for instance, 
above the knee, an ordinary bandage is applied from the toes up to just below 
the knee; and thus the blood is imprisoned in the desired region. In the 
intervals between the treatments the limb should be at rest. Bier uses 
special apparatuses for obtaining congestive hyperemia in various parts of the 
body. 

I have seen cure or very great improvement follow this treatment in a num- 
ber of cases. It is founded on the old idea of Laennec that cyanosis and 
tubercle are antagonistic. Why this method is beneficial is much debated. 
Some think that the imprisoned blood takes on increased bactericidal power; 
some, that the number of leukocytes is greatly increased; some, that quantities 
of leukocvtes migrate; and some, that the amount of bactericidal blood-serum 
is increased. Bier believes that it depends upon phagocytosis. It would seem 
possible that the cells in this locality, under the influence of the congestive 
hyperemia, may form powerful antitoxins. 

The Finsen Light. — Finsen pointed out that the chemical rays in sunlight 
are powerfully germicidal, and that this germicidal power can be notably in- 
creased if the rays are concentrated on a part by the use of particular apparatus. 
He also showed that enormous numbers of chemical rays can be obtained from 
electric light. The Finsen treatment to-day consists in applying the actinic 
rays obtained from electric light. They act most powerfully on lupus, but re- 
quire a very long time to effect a cure. 

The X-Rays. — The v-rays are of value in treating certain tuberculous 
conditions. They are of most use in lupus, their effects in this disease being 
nearly as powerfully curative as those of the Finsen light, and much more rapid. 

Tuberculous Abscess. — For description of this see page 145. 

Tuberculosis of the Skin. — Tuberculosis of the skin may arise from 
inoculation with material derived from a bovine or human source. It is fre- 
quently found that some other member of the family labors under tuberculous 
disease or that some family predecessor, direct or collateral, suffered from it. 
Stelwagon ("Diseases of the Skin") includes all cases under five heads: (1) 
tuberculosis ulcerosa; (2) tuberculosis disseminata; (3) tuberculosis verru- 
cosa; (4) scrofuloderma; (5) lupus vulgaris. 

Tuberculosis Ulcerosa. — The disease arises by a mucous outlet and is 
usually secondary to internal tuberculous disease. Small miliary tubercles 
form which caseate and are converted into ulcers. The ulcers are shallow, 
round or oval in outline, with soft edges, the floor being composed of sluggish or 
edematous granulations covered with a crust. The discharge is scanty and 
seropurulent. In some cases there is but one ulcer; in others there are two 
or several, and the fusion of ulcers produces a serpiginous outline. The ulcers 
do not heal, but gradually and steadily advance. Such ulcers are met with 
about the mouth, the genital organs, and the anus. 

Tuberculosis Disseminata. — This occurs only in children; it is acute in 
onset and widespread. One type is polymorphic: spots, papules, pustules, 
and crusted ulcers existing, and lymphatic glands being enlarged. Another type 
follows one of the exanthemata and presents "a rough resemblance to flat lupus 
tubercles, to sluggish acne papules, and to lichen scrofulosum" (Stelwagon). 

Tuberculosis Verrucosa. — Anatomical tubercle, the verruca necrogenica 
of Wilks, is due to local inoculation with tuberculous matter. It may be met 



230 Surgical Tuberculosis 

with in surgeons, the makers of post-mortems, leather-workers, and butchers, 
usually upon the backs of the hand and fingers. It consists of a red mass of 
granulation tissue having the appearance of a group of inflamed warts. Pus- 
tules often form. 

Scrofulodermata or tuberculous gummata. — By scrofulodermata we 
mean chronic inflammations of the skin, the granulation-tissue product of 
which caseates, mixed infection occurs, and small abscesses, sinuses, or ulcers 
form. A tuberculous ulcer has a floor of a pale color, and has no granulations 
at all, or is covered with large, pale, edematous granulations. The discharge 
is thin and scanty. The ulcer is surrounded by a considerable zone of 
purple, tender, and undermined skin, which is apt to slough. When healing 
occurs, the skin puckers and usually inverts. 

Lupus.- — Lupus begins usually before the age of twenty-five, but is met with 
often in individuals in middle life. It is most usual upon the face, especially the 
nose. It is a very chronic and extremely destructive disease. Three forms are 
recognized: (1) lupus vulgaris, in which pink nodules appear that after a time 
ulcerate and then cicatrize partly or completely. These nodules resemble 
jelly in appearance; (2) lupus exedens, in which ulceration is very great; and 
(3) lupus hypertrophicus, in which large nodules or tubercles arise. Lupus 
may appear as a pimple, as a group of pimples, or as nodules of a larger size. 
The ulcer arises from desquamation, and is surrounded by inflammatory 
products which, by progressively breaking down, add to the size of the raw 
surface. The ulcer is usually superficial, is irregular in outline, the edges 
are soft and neither sharp nor undermined, the sore gives origin to a small 
amount of thin discharge, the parts about are of a yellow-red color, the edges 
are solid and puckered and scar-like and there is no pain. The sore is often 
crusted, the crusts being thin and of a brown or black color; it may be pro- 
gressing at one point and healing at another; it is slow in advancing, but often 
proves hideously destructive. The scars left by its healing are firm and 
corrugated, but are apt to break down. Clinically it is separated from a ro- 
dent ulcer by several points. The rodent ulcer is deep, its edges are everted, 
and the parts about filled with visible vessels. It is not crusted, has not a puck- 
ered edge, its edges and base are hard and rarely show any tendency to healing. 

Tuberculosis of Subcutaneous Connective Tissue.— In this form 
of tuberculosis tuberculous nodules form and break down (tuberculous ab- 
scesses). In the deeper tissues these abscesses are usually associated with 
bone, joint or lymphatic gland disease (see Cold Abscess, page 145). 

Tuberculosis of the Mammary Gland.— (See page 152.) 

Tuberculosis of Blood=veSSels.— It is certain that bacilli in the blood 
or in tuberculous emboli may establish intravascular tuberculosis. 

Tuberculosis of nerve is excessively rare. Tuberculous neuritis may 
arise in the course of general tuberculosis. A nerve lying in a tuberculous 
area may itself become tuberculous. It rarely does so, however. In fact, 
nerves resist infections though in the midst of them, and for this reason have 
been called the "aristocrats of the body." 

Pulmonary Tuberculosis. — In adults the lungs are more commonly 
affected than any other structure. The lung affection may be primary or 
may be secondary to some distant tuberculous process. Pulmonary tubercu- 
losis belongs to the province of the physician and requires no description here. 



Tuberculous Disease of Fascia 231 

Tuberculosis of the Alimentary Canal.— A tuberculous ulcer of the 
lip occasionally arises, and may be mistaken for a cancer or a chancre. A 
tuberculous ulcer of the tongue is commonly associated with other foci of dis- 
ease. Such ulcers are separated from cancer by their soft bases and edges 
and by the rarity of glandular enlargements, and from syphilitic processes 
by the therapeutic test. Confirmation of the diagnosis is obtained by culti- 
vations and inoculations. Tubercle may affect the pharynx, palate, tonsils, 
and very rarely the stomach. It is thought that the acid gastric juice must 
protect the stomach from tubercle, because tubercle bacilli are frequently 
introduced into the stomach, but the organisms very rarely lodge and multiplv 
in the stomach- wall. 

Intestinal tuberculosis may follow pulmonary tuberculosis, but it may 
arise primarily in the mucous membrane of the bowel or result from tubercu- 
lous peritonitis. Intestinal tuberculosis causes diarrhea and fever, may re- 
semble appendicitis, and may cause abscess and perforation. True tubercu- 
lous disease of the appendix occasionally occurs. Tuberculosis of the cecum 
is by no means as rare as we used to believe (page 861). Fistula in ano is fre- 
quently tuberculous, and when it is, the lungs are very often involved, the pul- 
monary lesion being usually primary (page 1009). 

Tuberculosis of the Liver.— Tuberculous disease of the liver causes 
cold abscess or cirrhosis. 

Peritoneal tuberculosis may be primary, infection having been by way 
of the blood, may be part of a diffused process, or may follow intestinal tuber- 
culosis, the serous and muscular coats of the bowel having been at some point 
in contact or a follicular ulcer having perforated (Abbe). The germ may have 
entered by the Fallopian tube. It may be due to ovarian or Fallopian tuber- 
culosis, or to ulceration of a tuberculous appendix. It usually causes ascites, 
tympany, and tumor-like formations composed of adherent bunches of bowel 
or omentum or distended mesenteric glands (page 870). 

The heart muscle is rarely attacked by tuberculosis. In fact, valvular 
lesions of the left side of the heart actually protect the individual from pul- 
monary tuberculosis. Non-tuberculous endocarditis may arise in the course 
of a tuberculous process elsewhere. Tuberculous endocarditis does very 
rarely occur. 

The pericardium may be attacked with primary tuberculosis, or the 
process may be secondary to pleural tuberculosis. 

Tuberculosis of the pleura is not uncommon. Tuberculous pleurisy 
may be acute or chronic. In some instances mixed infection takes place and 
suppuration occurs. The tuberculosis may be primary, but is usually secon- 
dary to pulmonary tuberculosis, and may be due to direct extension or to 
rupture of an area of pulmonary softening. A primary pleurisy not due to 
traumatism is very apt to be tuberculous. 

Tuberculosis of the brain induces meningitis and hydrocephalus 
(page 717). 

Tuberculosis of the membranes of the spinal cord is seen alone 
or in association with tuberculous inflammation of the brain. 

Tuberculous disease of fascia is common; in fact, fascia is pecu- 
liarly prone to infection. Fascia may be attacked primarily, and when it is, 
the disease is apt to spread rapidly and widely and to produce most disastrous 



232 Surgical Tuberculosis 

results. The elder Senn regards tuberculosis of the intermuscular septa of the 
thigh as a very grave condition, which, if extensive, demands amputation of 
the limb. Secondary tuberculosis of fascia is far more common than the 
primary form, the original focus of disease being in bone, joint, tendon-sheath, 
or lymph-gland. 

Tuberculosis of muscle is rare. Instances of primary tuberculosis 
have been reported. Secondary tuberculosis is more common, but even this 
condition is rare, muscle seeming to have a high degree of resistance. 

Tuberculous disease Of bone is very common in youth, and usually 
a sprain or a contusion, which is oftener slight than severe, precedes any 
signs of the disease. The injury establishes a point of least resistance, and 
in the damaged area the bacilli are deposited and multiply, or else a latent 
area of tuberculosis is roused by the injury into activity. The organisms 
may be deposited directly from the blood, or may arrive in an embolism from 
a distant tuberculous focus (lung or lymph-gland) , which embolus is caught 
in a terminal artery in the end of a long bone and causes a wedge-shaped 
infarction. 

Tuberculous osteomyelitis, as a rule, begins just beneath the articular 
cartilage or in the epiphysis. There may be one focus, several foci or many 
foci in the same bone. The products of the tuberculous inflammation con- 
stitute tuberculous nodules which destroy the medullary tissue and hence 
cut off the nutrition of adjacent bone. Bone trabeculae are destroyed, and 
tuberculous granulations take their place, and here and there small dead 
portions of bone trabeculae lie as sequestra among the granulations. In some 
bones, for instance, the vertebrae and the bones of the corpus and tarsus, the 
tuberculous process spreads widely; in some it tends to remain localized. 
Tuberculous granulations may be absorbed, may be encapsuled, may be 
replaced by fibrous tissue, or may caseate (page 214). When an osseous 
tuberculous focus spreads and finally reaches the surface of the bone the 
stimulated periosteum produces new bone, while bone destruction is still 
going on within. Under such circumstances the bone enlarges and becomes 
spindle-shaped, as is seen in a phalanx, the seat of tuberculous osteomyelitis, 
the condition known as spina ventrosa. 

Tuberculous disease of the joints is called "white swelling" and 
also pulpy degeneration of the synovial membrane. Joints are especially liable 
to tuberculosis in youth, although the wrist and shoulder not infrequently 
suffer in adult life. Joint-tuberculosis is often preceded by an injury. The 
tuberculous process may begin in the synovial membrane. Primary synovial 
tuberculosis is most often met with in the knee-joint. Usually the disease 
begins in the head of a bone, dry caries resulting, necrosis ensuing, or an 
abscess forming which may break into the joint. 

Tuberculosis of lymphatic glands is known as "tuberculous aden- 
itis." It is the most typical lesion of scrofula. The common antecedent of 
tuberculous adenitis of the neck is slight glandular enlargement as a result of 
catarrhal inflammation of the mucous membrane of the mouth. Tuberculous 
adenitis is most frequent between the third and fifteenth years. A person not 
of the tuberculous type may acquire tuberculosis of the glands, but the disease 
is unquestionably of much greater frequency in those who are recognized as 
predisposed to tuberculosis. Tuberculous glands may get well, may even 



Rickets 233 

calcify, but usually caseate if left alone. Long after healing they may break 
down and soften (residual abscess of Paget). Tuberculous glands very fre- 
quently suppurate because of mixed infection. Though at first a local dis- 
ease, tuberculous glands may prove to be a dangerous focus of infection, fur- 
nishing bacteria which are carried by blood or lymph to distant organs or 
throughout the entire system. Glandular enlargement is in rare instances 
widely diffused, but it is far more commonly localized. Enlargement of the 
cervical glands is most common. Tuberculous disease of the mesenteric 
gland is known as tabes mesenterial. 

Cervical lymphadenitis may be confused with lymphadenoma. The 
former, as a rule, first appears in the submaxillary triangle; the latter, in the 
occipital or sternomastoid glands. Tuberculous glands weld together, they 
are apt to remain localized for a considerable time, and thev tend to soften. 
They may be accompanied by other tuberculous manifestations. Lymph- 
adenoma from the start affects many glands; it may arise simultaneouslv in 
several regions, although in some cases there is a distinct beginning in one 
region. Lymphadenoma shows very little tendency to suppurate, and does 
not break down except late in the course of the disease, and is accompanied 
by great debility and anemia. Malignant gland-tumors infiltrate adjacent 
glands and other structures, binding skin, muscles, and glands into one hard, 
firm mass. 

Tuberculosis of tendon=sheaths (tuberculous tenosynovitis) is dis- 
cussed on page 646. 

Tuberculosis of the Kidney.— (See page 1 114.) 

Tuberculosis may attack the Fallopian tubes, ovaries, or uterus. 

Tuberculosis of the urethra, prostate gland, seminal vesicles, 
and bladder is considered in the section on Regional Surgery. 

Tuberculosis of the Testicle.— This disease is not rare. It is 
sometimes primary, but is usually preceded by tuberculosis of the kidney, 
bladder, or prostate. But one testicle is affected in the beginning, but the 
other gland is apt to be attacked later. The tuberculous mass softens, be- 
comes adherent to the scrotum, and breaks or bursts, exposing the damaged 
testicle {fungus 0} the testicle). The cord is apt to be involved in tuberculosis 
of the testicle. 



XIV. RACHITIS, OR RICKETS. 

Rickets is a chronic disorder of nutrition arising during the early years 
of life (the first two or three) as a result of insufficient or of improper diet, 
aided and abetted in many cases by bad hygienic surroundings. A deficiency 
of fat and phosphate in the food or the use of a diet which, by inducing gastro- 
intestinal catarrh, prevents assimilation, causes rickets. It is characterized 
by incomplete osteogenesis and other nutritive failures. The disease is not 
common in nursing children unless breast-feeding has been unduly prolonged, 
and children fed upon artificial food are particularly apt to develop it. Holt 
says such diet is very deficient in fat and often in proteids, and contains an 
excess of carbohydrates ("Diseases of Infancy and Childhood"). J. Bland 
Sutton made some valuable experiments to indicate the injury done animals 



234 Rachitis, or Rickets 

by denying them natural diet. He fed lion cubs in the London Zoological 
Gardens on raw horse meat only and the animals developed rickets. The 
rickety animals rapidly recovered on feeding them with milk and powdered 
bones mixed with cod-liver oil. The disease is essentially a city malady, 
"being principally seen in children living in crowded tenements where the 
effects of improper food are most strikingly shown; yet even here the disease 
is rare in those who get a plentiful supply of good breast-milk " (Holt). Rick- 
ets must not be regarded as a bone disease. It is true the bones are affected, 
but so are various structures and organs, all of the disorders being due to an 
underlying nutritive defect. Some maintain that lactic acid, produced in the 
intestinal canal, causes bone inflammation, but most observers do not believe 
the bone changes are inflammatory. Children are very seldom born with 
rickets, but develop it later, the period of greatest liability being between the 
seventh month and the fifteenth month. So-called congenital rickets is usually 
sporadic cretinism. A child with rickets may become scorbutic (scurvy rickets) . 
Some regard rickets as the result of an infection. Others think it results 
from thymus atrophy (Mendel). 

Whatever may be the cause of rickets, the essential condition in the bones 
is an insufficient deposit of mineral matter in the new bone cells. The new 
bone is soft and vascular and bone lamellae toward the medullary canal 
are actually absorbed. There is excessive proliferation of cartilage which 
results in enlargement. The proliferating and imperfectly ossified cells 
cause enlargements at the ends of long bones and at the sternal ends of the 
ribs and various bones bend and are distorted. The parietal bone bulges 
on each side, the fontanels remain long open; there may be unossified gaps 
in the occipital bone, membrane only filling them (cranio-tabes) . There may 
be pigeon-breast, bent long bones, curved spine and distorted pelvis. The 
bones later may become firmly ossified in deformity. In rickets the spleen 
and liver are enlarged and the thymus is atrophied. 

Evidences of Rickets. — The condition is one of general ill-health; the 
child is ill-nourished, pallid, flabby; it has a tumid belly and suffers from 
attacks of diarrhea and sick stomach; it is disinclined for exertion and has a 
capricious appetite; it is liable to night-sweats; enlarged glands are often 
noted, the teeth appear behind time, and the fontanels close late. In health 
the posterior fontanel closes in the second month and the anterior fontanel in 
the eighteenth month. In rickets the anterior fontanel is often open when 
the child is three years of age. The sutures are often open at the end of the first 
year. The head is square in shape, the cranial bones are thick, and areas of 
thickening known as bosses appear over the parietal bones. The head is large 
and the forehead bulges. The long bones become much curved, the upper part 
of the chest sinks in, curvature of the spine appears, and the pelvis is distorted. 
The ligaments are relaxed and lengthened and the joints are wobbly. The 
muscles are feeble and ill-developed. Infantile convulsions are common. 
Nocturnal restlessness and night terrors are the rule. Laryngismus stridulus 
and tetany may occur. Swelling appears in the articular heads of long bones, 
by the side of the epiphyseal cartilages, and in the sternal ends of the ribs, 
forming in the latter case rachitic beads. The lesions of rickets are due to 
imperfect ossification of the animal matter which is prepared for bone-forma- 
tion, and the soft bones gradually bend. The swellings at the articular 



Scorbutus 



235 



heads arc due to pressure forcing out the soft bone into rings. Rachitic 
children rarely grow to full size, and the disease is responsible for many dwarfs. 
Most cases recover without distinct deformity, but the time lost during the 
period when active development should have gone on cannot be made up, and 
some slight deficiency is sure to remain. Bowlegs, knock-knees, and spinal 
curvatures are usually rachitic in origin. The disease may be associated with 
scurvy, inherited syphilis, or tuberculosis. In appearance the ricketv child is 
pot-bellied, pale and anemic, and usually fat and flabbv, though occasionally 
thin. There is great liability to enlargement of the tonsils, gastro-intestinal 
catarrh, and bronchial catarrh. The blood is deficient in red corpuscles 
and hemoglobin, and sometimes there is leukocytosis. The disease lasts for 
many months and is usually recovered from. It does not directly produce 
death, but is a powerful indirect cause of infant mortality because it lessens 
resistance and predisposes to many diseases. It is almost always afebrile; 
rarely congenital; and in unusual cases known as late rickets develops be- 
tween the fifth and tenth year. The so-called acute rickets is practically 
always scurvy (Holt). The victims of rachitis are very liable to fracture the 
bones from slight force and green-stick fractures are particularly prone to 
occur. After fracture of a rickety bone union is usually delayed. 

Treatment. — The treatment consists in having the child live as much as 
possible in the open air and sunshine. Salt-water baths are useful. Sea air 
is very beneficial. Fresh food (milk, cream, and meat-juice) should be 
ordered. Cod-liver oil, syrup of the iodid of iron, arsenic, and some form 
of phosphorus are to be administered. It is absolutely necessary to improve 
the primary assimilation. Slight deformities of the extremities require no 
special treatment unless they increase. If the deformity is marked or is in- 
creasing, use braces; employ massage, manipulation, and faradism. Holt 
points out that by the time the child is two years of age the bones are so firm 
that the pressure of a brace cannot cure the deformity. Hence after this age 
braces are useless. Pronounced established deformities of the extremities are 
usually treated surgically. Kyphosis is treated by making the patient lie upon 
a hard bed without a pillow. The child sits up a few hours each dav, the 
shoulders being held back and support applied to the body. In bad cases, 
during the time the child is erect it should wear a brace or plaster-of-Paris 
jacket. Daily manipulation, the child lying prone, is helpful. Friction and 
electricity to the spinal muscles do good. 

Scorbutus (Scurvy).— This disease is rare to-day in adults, but was at 
one time very common among those who took long voyages, or who engaged 
in campaigns, or were the victims of sieges. Of recent years it is very uncom- 
mon, and has occurred chiefly among voyagers in the Arctic regions or those 
who were beleaguered. Some years ago I saw several cases in a large alms- 
house. It is important to remember that though scurvy is rare in adults, it is 
by no means uncommon in ill-nourished infants. (A most graphic picture of 
scurvy as it used to occur will be found in "A Voyage Around the World," 
by Lord Anson. Compiled by the Rev. R. Walter.) 

Scurvy is a constitutional malady due to the consumption of improper diet, 
and especially to the employment of a diet characterized by the absence of 
vegetables. 

The use of salt meat as a staple article seems to favor the production of 



236 Rachitis, or Rickets 

the disease. Garrod considered absence of potassium salt to be the real 
cause. Absence of variety in diet, bad water, poorly ventilated quarters, and 
insufficient exercise favor the development of the disease. Some believe 
that an organic poison derived from tainted food is responsible (Torup). 
A bacterial origin has been suggested by Berthenson, Babes, and others. 
Certain studies made in the Transvaal suggest the bacterial origin of 
scurvy. Myer Coplans ("Lancet," June 18, 1904) states that it occurred 
in those getting excellent rations and began as inflammation of the gums, 
the constitutional symptoms following. If the gum condition was early 
recognized and cured simply by cleanliness and antiseptics, that is, by pure 
local treatment, constitutional trouble did not develop. 

Scurvy begins with weakness, drowsiness, muscular pains, and great 
susceptibility to cold. The skin is pallid or dirty white, and is occasionally 
mottled and often peels off. The patient is breathless on the slightest exer- 
tion. The pulse is excessively weak and slow. There is no fever. The 
gums may be tender and inflamed from the start, but in most cases they are 
not. After two or three weeks, usually the gums become tender, painful, and 
swollen, and bleed at frequent intervals; the breath becomes offensive, the 
teeth loosen and even drop out; subcutaneous hemorrhages take place, giving 
rise to petechias or extensive extravasations; the vision becomes dim; the 
urine becomes scanty and of low specific gravity; cutaneous vesicles form, 
rupture, and give rise to bleeding ulcers, and ulcers likewise arise from break- 
ing down of blood extravasations; hemorrhages take place into and between 
the muscles, and in severe cases beneath the periosteum and into joints, and 
blood may flow from the nose, lungs, kidneys, stomach, and intestines. Deep 
hemorrhages are felt as hard lumps. Bleeding at an epiphyseal line may 
separate the epiphysis from the shaft. If an inflammation or ulceration arises 
at any point, fever is observed. It was observed by DeHaven, who com- 
manded the Grinell expedition in search of Sir John Franklin, that scurvy 
causes old and soundly healed wounds to ulcerate. The same observation 
was made years before in Lord Anson's voyage. A sailor of the " Centurion " 
had been wounded fifty years before at the battle of the Boyne. He developed 
scurvy and the old wound opened. Most cases of scurvy get well under proper 
treatment, but complete recovery is not attained for a long time. Sudden 
death is liable to occur if any exertion is made. 

Captain Cook succeeded in preventing scurvy among his sailors by pro- 
viding plenty of fresh water; gaurding them against fatigue, wet, and extremes 
of heat and cold; attending to cleanliness and ventilation, and stimulating 
cheerfulness. This great navigator lost no men from scurvy. After the 
time of Captain Cook, the British Admiralty, acting on the suggestions of 
Lind and Blane, provided ships with lime-juice or lemon-juice with the 
most beneficial results in preventing the disease. Scurvy is prevented at the 
present time by employing a proper diet and by maintaining cleanliness and 
hygienic conditions. 

The following agents are believed to be especially useful as preventatives: 
fresh meat, lemon-juice, cider, vinegar, milk, eggs, onions, cranberries, cab- 
bages, pickles, potatoes, and lime-juice. When the disease develops, give 
vinegar, lemon-juice, onions, scraped apples, cider, nitrate of potassium, 
whiskey or brandy, and plenty of nourishing food. Antiseptic mouth-washes 



Contusions 237 

are necessary and strychnin is a valuable stimulant to the circulation. Sleep 
must be secured and ulcers are treated by antiseptic dressings and com- 
pression. 

Infantile scurvy or Barlow's disease may exist alone or with rickets 
(scurvy rickets). It occurs most often in the children of the well-to-do, those 
who have been brought up on artificial foods. It occurs between the eighth and 
eighteenth months of life. The child is anemic, suffers from gastro-intestinal 
disorders, spongy and bleeding gums, weakness of the legs, general muscular 
tenderness, night-sweats, and often febrile attacks (Rotch), bleeding from the 
nose, bleeding beneath the skin (blue spots), bloody urine and stools, bleeding 
beneath the periosteum, into joints, viscera, or muscles. In some cases hema- 
turia is the first and perhaps the only symptom (J. Lovett Morse, "Jour. 
Am. Med. Assoc.," Dec. 17, 1904). A subperiosteal hemorrhage is very 
dense, is tender, is fusiform in outline, and does not fluctuate. It is some- 
times mistaken for sarcoma. In one case seen by the author a hemorrhage 
beneath the periosteum of the femur was mistaken for a sarcoma. The 
limb attacked is flexed, and the child will not move it. Separation of an 
epiphysis may result from hemorrhage between it and the bone. Infantile 
scurvy is often unrecognized. If promptly treated, recovery is the rule, other- 
wise death may occur from exhaustion. 

Treatment. — Keep the child quiet in bed and give liberal amounts of cow's 
milk and beef-juice. Administer orange-juice, grape-juice, scraped apples, 
and tonics. To children over one year of age give potatoes. Antiseptic 
mouth-washes are necessarv. 



XV. CONTUSIONS AND WOUNDS. 

Contusions. — A contusion or bruise is a subcutaneous laceration, due to 
the application of blunt force, the skin above it being uninjured or damaged 
without a surface-breach and blood being effused. Punches, kicks, blows 
from a blackjack, etc., cause contusions. In intra-abdominal contusions 
the skin of the abdomen is frequently not damaged. In contusions of struc- 
tures overlying a bone the skin suffers with the deeper structures. If a large 
vessel is ruptured, hemorrhage is profuse and much blood gathers in the 
tissue. If only small vessels suffer, hemorrhage is moderate. An ecchymosis 
is diffuse hemorrhage over a large area, the blood lying in the spaces of the 
subcutaneous or submucous areolar tissue. A very small ecchvmosis is 
known as a petechia; a very large ecchymosis is called a sufjusion or extrav- 
asation. A hematoma is a blood-tumor or a circumscribed hemorrhage, 
the blood lying in a distinct cavity in the tissue. In extremely severe con- 
tusions tissue vitality may be destroyed or so seriously impaired that gangrene 
follows. Suppuration rarely occurs, but occasionally does so, and is most apt 
to in a drunkard or a person of dilapidated constitution. When hemorrhage 
arises in the tissues after a contusing force it soon ceases unless a very consid- 
erable vessel is ruptured. The arrest of hemorrhage is brought about bv the 
resistance of the tissues, the contraction and retraction of the vessels, coagu- 
lation of blood, and in some cases of severe injurv coagulation is favored 
b>y syncope. Blood in the tissues, as a rule, soon coagulates, the fluid ele- 



238 Contusions and Wounds 

ments being absorbed and the red corpuscles breaking up and setting free 
pigment, which pigment may be carried away from the seat of injury or may 
crystallize and remain there as hematoidin. In some cases inflammation 
occurs about the extravasated blood, a capsule of fibrous tissue being formed, 
and the blood being slowly absorbed, or the fluid elements remaining un- 
absorbed {blood-cyst), or the blood becoming thicker and thicker, finally cal- 
cifying. Blood in serous sacs (joints, pleura, pericardium) coagulates very 
slowly. As blood is being absorbed it undergoes chemical changes and 
color-changes ensue, the part being at first red and then becoming purple, 
black, green, lemon, and citron. The stain following a contusion is most 
marked in the most dependent area. After a bruise of the periosteum a 
blood-clot forms, much tissue-induration occurs, and a hard edge can be 
detected by palpation at the margin of the clot. 

Symptoms. — The symptoms are tenderness, swelling, and numbness 
followed by some aching pain Or a feeling of soreness. The pain rarely per- 
sists beyond the first twenty-four hours. Cutaneous discoloration appears 
quickly in superficial contusions, but only after days in deep ones. In some 
regions — the scalp, for instance — it can scarcely be detected; in others, as in 
the eyelid and vulva, discoloration is early, widespread, and marked. Dis- 
coloration and swelling are very marked in regions where loose cellular tissue 
abounds (eyelids, prepuce, scrotum). The discoloration is at first red, and 
becomes successively purple, black, green, lemon, and citron. The swelling is 
primarily due to blood, and is added to by inflammatory exudation. In a more 
severe contusion a hematoma may form. A recent hematoma fluctuates, but 
gradually, because of cell-proliferation, the edge becomes hard and the center 
continues to fluctuate. The mass gradually grows smaller and finally dis- 
appears. A subperiosteal hematoma of the scalp may be mistaken for depressed 
fracture of the skull. Any form of hematoma of the scalp may be mistaken 
for an abscess, but differs from it in the absence of inflammatory signs. It 
occasionally, though rarely, suppurates. In a case in which suppuration occurs 
an abrasion, which may be very minute, often exists on the skin. In any 
severe contusion there is considerable and possibly grave, or even fatal, shock. 

Treatment. — In a severe injury bring about reaction from the shock. 
Local treatment consists in rest, elevation, and compression to arrest bleeding, 
antagonize inflammation, and control swelling. Cold is useful early in most 
cases, but it is not suited to very severe contusions nor to contusions in the 
debilitated or aged, as in such cases it may cause gangrene. In very severe 
contusions employ heat and stimulation. When inflammation is subsiding 
after a contusion, compression and inunctions of ichthyol should be employed. 
Massage and passive motion are imperatively needed after contusion of a 
joint. If the amount of blood is very large, massage must not be used because 
it may cause embolism or fat-embolism. If a distinct cavity exists, aspiration 
or incision lessens the danger of fat-embolism. A contusion should never 
be incised unless the amount of blood is large and a distinct cavity ex- 
ists, or hemorrhage continues, or infection takes place, or a lump remains 
for some weeks, or gangrene is threatened. For persistent bleeding freely 
lay open the contused area, turn out clots, ligate vessels, insert drainage- 
strands or a tube, and close the wound. If gangrene is feared, make incisions 
and apply heat to the part. If a slough forms, employ antiseptic fomentations.. 



Shock 239 

The constitutional treatment for contusion, after the patient has reacted from 
shock, is the same as that for inflammation. (See Abdomen, etc.) 

Wounds. — A wound is a breach of surface continuity effected by a sudden 
mechanical force. Wounds are divided into open and subcutaneous, septic 
and aseptic, incised, contused, lacerated, punctured, gunshot, stab, and 
poisoned wounds. 

The local phenomena of wounds are pain, hemorrhage, loss of func- 
tion, and gaping or retraction of edges. 

Pain is due to the injury of nerves, and it varies according to the situation 
and the nature of the injury. It is influenced by temperament, excitement, 
and preoccupation. It may not be felt at all at the time of the injury. At 
first it is usually acute, becoming later dull and aching. In an aseptic wound 
the pain usually remains slight, but in an infected wound it always becomes 
severe. 

The nature and amount of hemorrhage vary with the state of the system, 
the vascularity of the part, and the variety of injury. 

Loss oj junction depends on the situation and extent of the injury. 

Gaping or retraction of edges is due to tissue-elasticity, and varies according 
to the tissues injured and the direction, nature, and extent of the wound. 

The constitutional condition after a severe injury is a state known as 
shock. 

Shock. — The name shock was introduced in 1795 by James Latta to 
designate the condition ensuing upon severe injury. (See G. C. Kinnaman, 
in "Annals of Surg.," Dec, 1903.) Shock is a sudden depression of the vital 
powers arising from an injury or a profound emotion acting on the nerve- 
centers and inducing exhaustion or inhibition of the vasomotor mechanism. 
Exhaustion is gradually induced; inhibition is suddenly produced. By over- 
stimulation of sensory nerves violent impressions are conveyed to the nerve- 
centers, the vasomotor center is exhausted or inhibited, vaso-constrictor 
power is lost, the arteries and capillaries are depleted or nearly emptied 
of blood, and the blood is largely transferred to the veins. The blood-pres- 
sure is lowered, the cardiac action is impaired, the respiratory action is impeded, 
and quantities of dark-colored blood gather in the somatic veins, but espe- 
cially in the veins of the splanchnic area. (See the masterly study of "Sur- 
gical Shock" by Crile.) In shock the abdominal veins are greatly distended 
and the other veins of the body may also be overfull, the arteries contain less 
blood than normal, and an insufficient amount of blood is sent to the heart 
and to the vital centers in the brain. In other words, in shock there is a 
deficiency in the circulating blood. The term collapse is used by some to 
designate a severe condition of shock, and is employed by others as a name 
for a condition of shock produced by mental disturbance rather than by 
physical injury. Crile regards collapse as inhibition of the vaso-motor cen- 
ter, in contrast to shock, which is exhaustion of the center. As a matter of 
fact, shock and collapse are often both present. That the bombardment 
of the nerve-centers by a tumult of peripheral impressions causes shock is 
shown by the fact that if the nerves from a part are thoroughly cocainized 
so that they will not transmit sensation, operation upon the part produces 
practically no shock. Crile calls such cocainization the introduction of a physi- 
ological block. Shock may be slight and transient, it may be severe and 



240 Contusions and Wounds 

prolonged, and it may even produce almost instant death. Sudden death 
from shock is due to reflex stimulation of the pneumogastric nuclei and arrest 
■of cardiac action. It is known as death by inhibition. Shock is more severe 
in women than in men, in the nervous and sanguine than in the lymphatic, in 
those weakened by suffering than in those who are strangers to illness. It is 
predisposed to by fear, by disease of the kidneys, diabetes, chronic cardiac 
disease, and alcoholism. Injuries of nerves, of brain, of the intrathoracic 
viscera, of the intra-abdominal viscera, of the urethra, or of the testicle pro- 
duce extreme shock. Anything which extracts the body-heat favors the 
development of shock (exposure to cold air, insufficient covering, chilling the 
body by solutions or wet towels). Cerebral concussion is shock plus other 
conditions. Sudden and profuse hemorrhage causes shock; so does prolonged 
anesthetization. Great shock may occur after the removal of a large tumor 
or a quantity of fluid from the abdomen. In such a case shock is brought 
about by the sudden removal of pressure and the consequent rapid distention 
of intra-abdominal veins. Exposure of tissue and vital parts to air aggra- 
vates shock. 

Symptoms. — The symptoms of ordinary shock {torpid or apathetic shock) 
are subnormal temperature; irregular, weak, rapid, and compressible pulse; 
cold, pallid, clammy, or profusely perspiring skin; and shallow and irregular 
respiration. Consciousness is usually maintained, but there is an absence 
of mental originating power, the injured person answering when spoken to 
but volunteering no statements and lying with partly closed lids and expres- 
sionless countenance in any position in which he may be placed. The an- 
swers to questions though apparently intelligent are utterly unreliable. The 
pupils are dilated and react but slowly to light. The sphincters are relaxed. 
Pain is slightly or not at all appreciated. Nausea is absent and vomiting 
may, as in concussion, presage reaction. Gastric regurgitation, after a con- 
siderable duration of shock, is not unusual, and is a bad omen. Shock is not 
rarely followed by suppression of urine. Whereas the victim of shock is 
usuallv stupid and indifferent, he may become delirious. If delirium arises, 
the condition is very grave. Travers called shock with delirium erethistic or 
delirious shock. As a matter of fact, such a state is not genuine shock 
but is either a traumatic or a toxic delirium. It is usually due to uremia or 
sepsis. Delirious shock is seen after a person has been bitten by a poisonous 
snake. Many years ago Travers described a secondary or delayed form of 
shock, which comes on several hours after an injury or violent emotional 
disturbance. This form of shock is seen not unusually in those who have 
passed through a railroad accident. It may be a sign of hemorrhage, and is 
sometimes met with after the administration of ether or chloroform. The 
statements made by a person who has recovered from a severe shock are always 
unreliable as to events which occurred while shock existed, and are often 
doubtful as to the details of the accident. Not unusually the memory of 
the accident is perverted or even destroyed. 

Diagnosis. — Concealed hemorrhage is difficult to differentiate from shock. 
It produces impairment of vision (retinal anemia), irregular tossing, frequent 
yawning, great thirst, nausea, and sometimes convulsions. In shock the 
hemoglobin is unaltered; in hemorrhage it is enormously reduced (Hare and 
Martin). In hemorrhage recurrent attacks of syncope are met with. In 



The Prevention of Shock in Operations 



241 



pure shock such attacks do not occur. In concealed hemorrhage the abdomen 
may exhibit physical signs of a rapidly increasing collection of fluid. Shock 
and hemorrhage are often associated. The essential characteristic of shock 
is rapid onset, which separates it distinctly from exhaustion. It arises at a 
much earlier period after an injury than does fat-embolism. 

The Prevention of Shock in Operations. — Examine the patient with 
care before operating, giving special attention to the condition of the kidneys. 
The amount of urine passed and the amount of urea it contains should always 
be determined when possible. The amount of urea should be estimated from 




Fig. 90. — Subcutaneous saline infusion (Senn). 



the twenty-four hours' urine. The normal amount of urine in the twenty- 
four hours is about fifty ounces and the normal amount of urea 2 per cent. 
Less urea is significant of danger from shock and subsequent kidney complica- 
tions. If the condition of the patient leads us to fear that there will be dan- 
gerous shock, do not purge him severely before operation, and just previous 
to operation give a rectal injection of hot saline fluid and a hypodermatic in- 
jection of y-^-Q of a grain of atropin. It is also a good plan in some cases to give 
a hypodermatic injection of gr. § of morphin twenty minutes before operation. 
It tranquillizes the patient and less ether will be needed to anesthetize him. 
Examine the patient thoroughly and prepare him carefully beforehand and 
16 



242 



Contusions and Wounds 



decide if he should take a general anesthetic at all, and, if so which one. In 
some cases a local anesthetic should be used, for instance, some cases of 
typhoid perforation and strangulated hernia. 

Occasionally the nerves from the damaged part should be infiltrated with 
cocain (Crile). This prevents the ascent of peripheral impressions, makes 
what Crile calls a "physiological block," and so prevents shock. After this 
infiltration a limb can be amputated below the infiltrated area without pain 
and without depression of the vital powers. In some few cases in which we 
fear shock spinal anesthesia is used; in others scopolamin and morphia. 
If a general anesthetic is used it must be skillfully given and not a drop is 
given beyond the amount necessary to maintain thorough anesthesia. Cover 
every part but the field of operation with hot blankets and put cans of hot 
water about the patient, or put him on a bed composed of hot-water pipes 
covered with blankets. Prevent bleeding with the greatest possible care. 
Operate as rapidly as is consistent with safety and thoroughness. If shock 
develops during an operation hasten on the work, lessen the amount of ether, 
and apply active treatment. Return the patient to bed as soon as possible 
and without exposure in cold halls or a windy elevation. Occasionally it 
becomes necessary to suspend an operation in order to prevent death on the 
table. 

Treatment. — In treating ordinary apathetic shock raise the feet and lower 
the head, unless this position causes cyanosis. At least place the head flat 

and the body recumbent . 
Wrap the patient in hot 
blankets and surround 
him with hot bottles, hot 
bricks, hot-water bags 
or cans of hot water. 
Always wrap a can, a 
bottle, or a bag in flan- 
nel, to avoid burning 
the patient. Ordinary 
stimulants seem of but 
little value and drugs 
given by the stomach 
are not absorbed. Salt 
solution may be thrown 
into a vein (intravenous 
infusion), may be given 
by the rectum (enter o- 
clysis), or subcutane- 
ously (hypodermody- 
sis). Intravenous infu- 
sion does good, but, unfortunately, the benefit is very temporary except in 
cases associated with hemorrhage. In hemorrhage it should always be given. 
The operation of intravenous infusion is described on page 400, and the 
manner of incising the vein and inserting the tube is shown in Fig. 91. 
Crile maintains that the only way " to increase and sustain the blood-pressure 
when the vasomotor center is exhausted" is to "create a peripheral resistance 




Fig. 91. 



-Intravenous saline infusion. Manner of incising vein 
and inserting glass tube (Senn). 



Treatment of Shock 243 

either by a drug acting on the blood-vessels themselves or by mechanical 
pressure."* The proper drug to use is adrenalin chlorid. Because of the 
rapidity with which this drug is oxidized, Crile gives it intravenously and 
continuously, using a solution of a strength of from 1 in 50,000 to 1 in 100,000 
in salt solution. It is given slowly from a buret, "the rate of flow being 
controlled by a screw-cock attached to the rubber tube." Crile also places 
the patient in a rubber suit and distends the suit by means of an air pump 
and thus obtains equable pressure upon the cutaneous surface and an increase 
of peripheral vascular resistance. Since the publication of Crile's paper I 
have used adrenalin chlorid in shock in preference to strychnin, and am 
satisfied that it is greatly superior to the latter drug. A preparation of a 
solution of adrenalin chlorid is on the market which can be readily added to salt 
solution until the proper degree of dilution is obtained. Ateaspoonful of this 
solution contains the drug in the proportion of 1 part to 1000, and this amount 
should be added to 1 liter of salt solution. The use of hot and stimulat- 
ing rectal enemata is important. The rectum may absorb fluids when the 
stomach refuses to do so. Enemata of hot normal salt solution are beneficial 
(enter ocly sis). The tube is carried to the sigmoid flexure and the injec- 
tion is introduced so as to distend the colon. Hypodermodysis is given as 
follows: Insert an aspirator tube into the cellular tissue of the loin, scapular 
region, or under the mamma, cleansing the part first. The tube is attached 
to a fountain syringe, which is filled with normal salt solution, and is hung 
at a height of two or three feet above the bed (Fig. 90). In an hour's time 
a pint or more of fluid will enter the tissue and be absorbed. It is the custom 
to give hypodermatic injections of ether, brandy, strychnin, digitalis, or 
atropin, or inhalations of amyl nitrite. Crile has demonstrated experiment- 
ally that strychnin is perfectly futile in pure shock and may actually aggra- 
vate the condition. In collapse it is of some value. We believe this statement 
is true clinically. Strychnin goads a heart to increased action when that 
organ has not sufficient blood passing into it to enable it to firmly and strongly 
contract; the use of strychnin in shock has been compared by Hare to beat- 
ing a dying horse to make it pull. I believe that atropin is of great benefit in 
shock, especially if the skin is very moist. This drug, according to my colleague, 
Prof. Hobart A. Hare, is a sedative to the vagus; but what makes it 
particularly valuable is that it acts upon the vasomotor system, combats 
the dilatation of the blood-vessels, maintains vascular tone, prevents stagna- 
tion of blood in any vessels, and increases the amount of moving blood. 
If the skin is very moist, atropin is particularly indicated. Senn recommends 
the hypodermatic injection of sterile camphorated oil, a syringeful every 
fifteen minutes until reaction begins. Inhalation of oxygen is often of much 
service, and artificial respiration may be necessary. Opiates are contra- 
indicated in shock. Mustard plasters should be placed over the heart, spine, 
and shins. A turpentine enema is useful. An enema of hot coffee and 
whiskey is valuable. In severe cases of shock, bandage the extremities. 
Bandaging for the relief of shock is called autotransfusion. This procedure 
increases peripheral resistance and enables the body to utilize to the best 
advantage the small amount of circulating blood, and sends most of it to the 
brain, where it will maintain the activity of the vital centers and keep up cir- 
* George Crile, in Boston Med. and Surg. Jour., March 5, 1903. 



244 Contusions and Wounds 

culation and respiration. For this purpose ordinary muslin bandages may 
be used, or gauze bandages, or the bandages of Esmarch. Crile's rubber 
suit accomplishes the object more satisfactorily than does bandaging the 
extremities. Abdominal massage helps drive out the imprisoned blood, 
and after massage sets free the abdominal blood apply a compress and binder. 
In serious cases artificial respiration and stimulation of the diaphragm with 
a galvanic current may be used. If shock comes on during an operation, 
the operation must be hurried or even abandoned, and proper treatment must 
be instituted at once. The anesthetist should give very little ether when 
shock becomes at all evident. Should we operate during shock ? We should 
only do so when death without instant operation is inevitable. We must 
operate, if it is necessary to do so, to arrest hemorrhage, to relieve strangu- 
lated hernia, intestinal obstruction, obstruction of the air-passages, compound 
fractures of the skull, extravasated urine, or intraperitoneal extravasations 
from ruptured viscera. If hemorrhage can be temporarily controlled by 
pressure or a clamp, so much the better, and the permanent arrest can be 
effected after the reaction from shock. It is not wise, in the author's opin- 
ion, to amputate during shock. A tourniquet or Esmarch bandage should be 
applied, and attempts be made to bring about reaction, and when reaction 
is obtained the amputation should be performed. It is only just to say that 
some eminent surgeons oppose this rule. Roswell Park says that "shock is 
often alleviated by the prompt removal of mutilated limbs which, when still 
adherent to the trunk, seem to perpetuate the condition." The same 
teacher believes in operating at once upon severe compound fractures.* 
After every operation keep careful watch upon the amount of urine passed, 
see to it that the patient takes sufficient fluid, and if the urine becomes scanty 
put a hot-water bag over the kidneys, give diuretics by the mouth, secure 
cutaneous activity, give saline purgatives, and administer hot saline enemata. 
If the condition is not soon benefited, the custom is to infuse hot saline fluid 
into a vein. I am doubtful if intravenous infusion of saline fluid is benefi- 
cial in suppression, and I even fear it may do harm (see the studies of Widal, 
Marie and Crouzon, Merklen, and others). In urinary suppression following 
accident or surgical operation (post-operative suppression or anuria) the condi- 
tion is so dreadfully grave that it is justifiable to expose each kidney and split 
the capsule in order to relieve tension and in the hope of thus abating congestion. 
Post-operative suppression of urine is almost invariably fatal. Delayed shock is 
treated in the same manner as apathetic shock if hemorrhage can be excluded. 
If hemorrhage is the cause, the bleeding must be arrested. If delirious shock is 
due to sepsis, the treatment is that of sepsis. If it is a nervous delirium give 
morphin and other sedatives. If due to uremia, the treatment is obvious. 

Fat=embolism.— (See page 191.) 

Fever. — (See Fevers, page 123.) 

Treatment of Wounds. — All wounds, other than those made by the 
surgeon, are regarded as infected. The rules for treating such wounds are: 
(1) arrest hemorrhage; (2) bring about reaction; (3) remove foreign bodies; 
(4) asepticize; (5) drain, coaptate the edges, and dress; and (6) secure rest 
to the part and combat overaction of the tissues. Constitutionally, allay 
pain, secure sleep, maintain the nutrition, and treat inflammatory conditions. 
* Park's "Surgery by American Authors." 



Treatment of Wounds 245 

Arrest of Hemorrhage. — To arrest hemorrhage the bleeding point must be 
controlled by an Esmarch band or digital pressure until ready to be grasped 
with forceps; it is then caught up and tied with catgut or aseptic silk. Slight 
hemorrhage ceases spontaneously on exposure of the bleeding point to air, 
and moderate hemorrhage ceases permanently after the temporary 7 applica- 
tion of a clamp. An injured vessel when not of the smallest size must be 
ligated, even if it has ceased to bleed. Capillary oozing is checked by hot 
water and compression. If a large artery is divided in a limb, apply a tourni- 
quet before ligating (see Wounds of Vessels). 

Bringing about 0} Reaction. — (See Shock.) 

Removal of Foreign Bodies. — Remove all foreign bodies visible to the eye 
(splinters, bits of glass, portions of clothing, gun-wadding, grains of dirt, etc. ) 
with forceps and a stream of corrosive sublimate solution, sterile water, or 
normal salt solution. In a lacerated or contused wound portions of tissue 
injured beyond repair should be regarded as foreign bodies and be removed 
with scissors. 

Cleaning the Wound. — To clean the wound shave the surrounding area, 
if it is haiiy; scrub the surface about the wound with ethereal soap, green 
soap, or castile soap, wash with water, scrub with alcohol, and then with 
corrosive sublimate solution (1 : 1000). An accidental wound is infected, 
and must be well washed out with an antiseptic solution. A clean wound 
made by the surgeon need not be irrigated; in fact, irrigation with an anti- 
septic fluid leads to necrosis of tissue, causes a profuse flow of serum, and 
necessitates drainage. If clots have gathered in a wound, they must be 
removed, as their presence will prevent accurate coaptation of the edges. 
In an infected wound they are washed out with a stream of corrosive solu- 
tion. In a clean wound they are washed out with hot salt solution. If 
dirt is ground into a wound, as is often seen in crushes, pour sweet oil into 
the wound, rub it into the tissues, and scrub the wound with ethereal soap. 
The oil entangles the dirt, and the soap and water remove both oil and dirt. 
After the rough cleansing irrigate with corrosive sublimate solution. In 
some cases, especially in bone-injuries, it is necessary to scrape the wound 
with a curet. If a fissure of the skull is infected, enlarge the fissure with 
a chisel in order to clean it. In a badly infected wound one of the most 
valuable agents for use in producing disinfection is pure carbolic acid. After 
cleaning the wound, it is necessary in certain regions to examine in order 
to determine if tendons or considerable nerves have been cut. If such struc- 
tures have been divided, they must be sutured with fine silk, chromic gut, 
or kangaroo-tendon. 

Drainage, Closure, and Dressing. — Superficial wounds require no special 
drainage, as some wound-fluid will find exit between the stitches and the rest 
will be absorbed. A large or deep wound requires free drainage for at least 
twenty-four hours by means of a tube, strands of horsehair, silk, or catgut, 
or bits of iodoform gauze. An infected wound must invariably be drained. 
Good drainage may, to a considerable extent, compensate for imperfect anti- 
sepsis. If capillary drains be employed, apply a moist dressing. Approxi- 
mate the edges with interrupted sutures of silk or silkworm-gut if the wound 
is deep and considerable tension is inevitable. Catgut is used for superficial 
wounds and for those where tension is slight. If there is decided tension, 



246 



Contusions and Wounds 



silver wire may be used. In very deep wounds buried sutures must be used. 
These sutures may consist of absorbable material (kangaroo-tendon or cat- 
gut) or unabsorbable material (silver wire). If the wound is infected, dress 
with warm, moist antiseptic gauze. If it is not infected, dress with dry 
sterile gauze. The custom once was to cover even dry gauze with a rubber 
dam to diffuse the fluids, but we now prefer to omit the rubber dam and use 
plentiful dressings. A dry dressing absorbs wound fluids quickly and is less 
likely to become infected. Change the dressings in twenty-four hours, or 
sooner if they become soaked with discharge. Dressings are changed for 




Fig. 92.— Muscle suture: A, Transverse wound of biceps muscle, showing marked retraction of 
muscle-ends and mattress suture in place ; B, muscle suture completed (Senn). 



cause, but not according to scheduled time. They must, of course, be changed 
when they become soaked with wound-fluid, and soaking may occur in a few 
hours, but may not occur for days. As long as the temperature remains 
normal, and the wound free from pain, if the dressing is not wet with discharge, 
it can be left in place unless removal is necessary to take out a drainage-tube. 
If pus forms, open the wound at once. Many surgeons sprinkle wounds 
before approximation and wound surfaces after approximation with a drving- 
powder. These powders are of great use in infected wounds, but are not 
necessary in clean wounds. Among the substances employed are salicylic 
acid, boric acid, calomel, acetanilid, aristol, iodoform, subiodid of bismuth, 



Incised Wounds 



247 



and glutol. In large wounds which cannot be approximated it is occasionally 
advisable to skin-graft by Thiersch's method. A small wound which cannot 
be sutured is dusted with an antiseptic powder and dressed. A granulating 
wound is dressed as is a healing ulcer. A sloughing wound is opened, is 
dusted with iodoform or acetanilid, and is dressed with hot antiseptic fomen- 
tations. 

Rest. — Severe wounds require the confinement of the patient to bed. 
Bandages, splints, etc., are used to secure rest. The methods of combating 
inflammation have previously been set forth. 

Constitutional Treatment. — Bring about reaction from depression, but pre- 
vent undue reaction. Feed the patient well, stimulate him if necessary, 
attend to the bowels and bladder, secure sleep, and allay pain. Watch for 
complications, namely, inflammation, suppuration, gangrene, tetanus, ery- 
sipelas, suppression of urine, and pneumonia. Observe the temperature 
closely; it may be a danger-signal of urgent importance. 




Fig. 93. — Suturing of tendons and nerves in incised wounds : 

nerve suture (Senn). 



a. Primary tendon suture; b, primary 



Incised Wounds. — An incised wound is a clean cut inflicted by an edged 
instrument. Only a thin film of tissue is so devitalized that it must die. 
These wounds have the best possible chance of union* by first intention. 

The pain may be very severe; but if the instrument is sharp and used 
quickly it may be trivial. The pain is less severe than that caused by some 
other varieties of wounds. The acute pain does not last long, and is followed 
by smarting. The hemorrhage is profuse, varying, of course, with the region 
cut. Bleeding from the scalp is violent, because there are numerous vessels 
which lie in fibrous tissue and cannot retract nor contract. The edges of 
incised wounds retract because of tissue-elasticity, and the wound "gapes." 
If the skin or fascia? are divided at a right angle to the muscle beneath, there 
is wide gaping. If the cut is parallel to the muscle-fibers, the gaping is slight. 



248 



Contusions and Wounds 



When the skin is violently pulled upon, it tends to split in a certain line. 
Langer and Kocher speak of this as the line of cleavage, and point out the 
direction of these lines in various situations. A cut across the line of cleavage 



The right way. 





Fig- 95- — Tying an interrupted suture. The 
knot is placed to the side of the wound as 
shown in Fig. 94. 



The wrong way. 



Fig. 94. — The interrupted suture (after Bryant). 




Fig. 96.— Continuous suture. 



is followed by wide gaping. A cut in the direction of the line of cleavage pro- 
duces slight gaping, and is followed by a trivial scar. 

When a muscle is cut across, the wound edges widely separate. When a 
tendon is completely cut across, extensive separation occurs. 





Fig. 97.— Ford's suture: a square knot, a 
single knot, a double or friction knot, and 
the first method of passing the needle to tie 
a single knot immediately. 



Fig. 98. — Ford's suture : showing two square 
knots, a single knot, and the method of com- 
pleting a square knot. 



An incised wound can be thoroughly inspected, all divided structures can 
be identified, foreign bodies can be easily removed, and disinfection can be 
satisfactorily carried out. 



Incised Wounds 



249 



Treatment. — According to general principles. Arrest hemorrhage, asep- 
ticize, etc. 

Examine the wound carefully to see if a nerve, a tendon, or a muscle is 
divided, and if such injury is discovered, suture at once (Figs. 92 and 93). 
If the wound is extensive or deep, it may be necessary to use buried sutures 
in order to keep the sides of the wound in contact. If the surface of a wound 
is approximated, but the depths are not, the dead space or cavity becomes 
filled with fluid, and infection almost certainly occurs. If buried sutures have 
not been used, such a cavity must be obliterated by the judicious application 
of pressure upon the surface. This is secured by the adaptation of a mass of 
loose or fluffed-up gauze, and the firm application of a bandage or binder. An 
incised wound is usually closed with interrupted sutures (Figs. 94 and 95). In 
adjusting the sutures, see that the edges of the wound are not inverted, but 
are neatly adjusted, and that the knot does not lie upon the wound line, but 
rests to the side of it. Tie the stitches firmly but not tightly. If a stitch is tied 
too tightly it will make a furrow, as shown in Fig. 94, and undue tightness is 
sure to cause necrosis, and is often productive of a stitch-abscess. A silk suture 
and a catgut suture should be tied with the reef knot; a suture of silkworm- 
gut should be tied with a surgeon's knot. If a wound is on the face, particular 
care must be employed in closing it, in order to limit the amount of disfigure- 
ment. In a clean wound stitches can, as a rule, be removed in from six to 
eight days. In a large wound one-half the stitches are removed at one sitting, 
and in a day or two the rest are removed. Stitches are promptly removed if 
they begin to cut out or if infection occurs. 

The old continued suture is rarely used for skin-wounds at the 
present time. This suture is employed to suture the dura after division, to 
suture the two layers of pleura together before an abscess of the lung is opened, 
to suture the peritoneum after laparotomy, and to suture the mucous mem- 
brane after certain operations upon the stomach. The continued suture is 
shown in Fig. 96. A continuous suture knotted after each emergence was 
devised by Ford. It is very useful in suturing the parietal peritoneum 
(Figs. 97 and 98). 

Halsted's subcuticular stitch (Fig. 99) makes a most perfect closure of the 
skin-wound, and is followed by the smallest possible scar. It is only used 
in wounds which are almost certainly clean, as those made by the surgeon, 
and in wounds which do not require drainage. The suture material should 
be of silver wire caught upon a curved Hagedorn needle or silkworm-gut 
carried by a long, straight, round needle. The suture is passed through 
the corium on each side of the wound, as shown in Fig. 99. The curved 
needle must be held in the bite 
of a needle-holder. When the 
suture has been passed the ends 
are pulled upon, and the skin- 
wound closes neatly. 

Halsted's suture does not pene- 
trate the cuticle; hence, in pass- 
ing it the white staphylococcus 
is not carried through stitch-holes 
and into the wound, an accident which might be followed by infection of a 




Fig. 99. — Halsted's subcuticular suture, 
true skin. 



A is the 



25° 



Contusions and Wounds 



stitch-hole or even of the wound. When it is desired to withdraw this suture, 
take one end in the bite of a forceps, cut it off short with scissors, and pull 
steadily upon the other end. 





Fig. 102. — The twisted suture. 



Fig. ioo. — The quilled suture. 

In very deep wounds or wounds in which there is much tension after 
approximation the quilled suture (Fig. ioo) or the button 
suture (Fig. ioi) may be used. The twisted suture, or 
harelip suture, is shown in Fig. 102. 

Problems of drainage, dressing, etc., are discussed on pages 
70, 71, and 72. 

If infection occurs, the wound 
becomes swollen, tender, pain- 
ful, and discolored, and the 
temperature of the patient 
soon becomes elevated. In 
such a condition cut the 
stitches, disinfect, and drain. 

Wounds of Mucous Mem- 
branes. — If the surgeon intends 
to inflict a wound upon a mu- 
cous surface, he should see to it that the patient's general 
condition is good. Thorough asepsis is impossible, and a 
good result depends largely upon the vital resistance of the tissues. 
Before operating, irrigate the part frequently with boric acid, peroxid 
of hydrogen, or normal salt solution. When ready to sew up the wound 
be sure that all irritant fluids are removed (saliva in the mouth, etc.). 
Cleanse the wound with hot normal salt solution. The stitches must include 
submucous tissue as well as the mucous membrane, and consist of silver wire, 
silk, chromic catgut, or silkworm-gut. After sewing up a wound in the 
mouth, wash the cavity at frequent intervals with salt solution, and follow 
each washing with an insufflation of iodoform. 

In accidental wounds irrigate with salt solution, dust with iodoform, and 
close as directed above. Corrosive sublimate is so irritant that it does harm 
when applied to a mucous membrane. 

Contused and Lacerated Wounds. — A contused wound results from a 
blow or a squeeze which bruises and crushes the tissues and splits or ruptures 
the skin. It is a common injury when force is applied to tissues over a bone. 
The blow of a blackjack may cause either a contusion or a contused wound 
of the scalp. A contused wound is irregular in outline, with jagged edges, and 



Fig. 101. — Button 
suture. 



Contused and Lacerated Wounds 251 

is surrounded by a broad zone of contusion. The worst form of contused 
wound is a crush of an extremity produced by being run over. The skin is 
often widely separated from the tissues beneath. 

A lacerated wound results from tearing apart of the tissues. It too is 
irregular and jagged, and is accompanied by more or less contusion. A 
brush-burn is a contused-lacerated wound due to friction. Both lacerated 
and contused wounds contain masses of partly detached and damaged tissue, 
the vitality of which is endangered. Nerve-trunks, muscles, and great 
vessels may be torn across. Hence, such wounds are apt to slough, fre- 
quently suppurate, and are occasionally followed by cellulitis or even by 
gangrene. There is more danger of tetanus than in incised wounds. A wound 
especially apt to be followed by tetanus is made by the toy pistol. In con- 
tused and lacerated wounds the edges are discolored and cold to the touch, 
and there is little primary hemorrhage unless a cerebral sinus is opened 
or a great vessel is torn. There is considerable danger of secondary 
hemorrhage if large vessels have been bruised. In wounds of this nature the 
pain is often slight, but it may be violent. Shock is very severe. 

Avulsion of a limb is a dreadful form of lacerated wound. The thumb 
or a finger may be torn off or the arm may be wrenched from the body with 
or without the scapula. In such cases the wound is large, jagged, and irreg- 
ular, long strings of muscle or tendon hang from the gap, the wound edges 
are cold, but the bleeding is trivial. The shock is, of course, profound. 

Avulsion of the scalp may be produced when the hair is caught in machin- 
ery. The American Indian inflicts this injury when he scalps a conquered 
foe. In some cases of avulsion of the scalp the periosteum is removed with 
the flap; in most it is not. The flap usually consists of skin and aponeurosis. 
In this form of laceration there is severe bleeding. 

Treatment. — The surgeon brings about reaction and endeavors to asepticize 
the wound and skin about it (page 245), arrests hemorrhage, and ligates any 
visible damaged vessel whether it bleeds or not. Hopelessly damaged tissue 
should be cut away, doubtful tissue being retained. In some cases amputation 
is necessary. Secure thorough drainage, in some situations making counter- 
openings if necessary. Tube-drainage may be necessary or iodoform gauze 
in strands may be used. Contused wounds and lacerated wounds, except 
when on the face, are seldom closed by sutures. They are rarely closed because 
the damage is so great and the blood-supply so interfered with that primary 
union will not occur. In the face the blood-supply is so good that primary 
union may be obtained in part or entirely, and it is worth while to try to obtain 
it. Cold must not be applied to a region of lowered vitality, because it might 
cause gangrene. Heat is useful. Hence, it is advisable, even from the start, 
to dress with hot antiseptic fomentations, and this mode of dressing becomes 
imperative if sloughing begins. Of course the part must be kept at rest. 

If suppuration occurs, the surgeon sees to it that the pus has free exit, and 
if necessary secures free exit by making incisions. 

After avulsion of a limb the patient is reacted from shock, large vessels are 
sought for and tied, damaged tissue is cut away, the wound is packed with 
gauze and is partly approximated by sutures. After avulsion of the scalp 
bleeding vessels are carefully ligated. A portion of the scalp may be torn 
away, but a pedicle may connect it with the balance of this structure. In such 



252 Contusions and Wounds 

a case cleanse the parts thoroughly and suture the flap in place (W. T. 
Bivings, "Phila. Med. Jour.," June 7, 1902). If the portion of scalp is 
entirely separated, adopt Gussenbauer's suggestion when possible and graft 
pieces of the avulsed scalp. In any case the ulcer resulting from avulsion 
must be repeatedly grafted. Abbe in a case obtained healing after four years 
by the use of 12,000 grafts. 

Punctured Wounds. — Punctured wounds are made wth pointed instru- 
ments, as needles, splinters, etc. The depth of a punctured wound greatly 
exceeds its surface area. After the withdrawal of the instrument inflict- 
ing the injury the wound partly closes at points, blood and wound-fluid can- 
not find exit, and if, as is probably the case, bacteria were deposited in the 
tissues, infection with pus organisms is very likely to occur, and if it does occur 
suppuration spreads widely. There is also danger of infection with tetanus 
bacilli. Such a wound may involve an important blood-vessel, and in such a 
case profuse hemorrhage may occur; otherwise hemorrhage is slight. A great 
cavity of the body may be penetrated or an important organ may be wounded. 
Large-sized foreign bodies may be driven into the tissues or a portion of the 
instrument may break off and lodge. Pain is rarely severe unless a consid- 
erable nerve has been damaged. If both a large vein and artery are punctured, 
varicose aneurysm or aneurysmal varix may arise. 

Treatment. — When possible, inspect the instrument which did the dam- 
age to see if a piece has been broken off. If there is severe hemorrhage, 
enlarge the wound and tie the bleeding vessels. In a puncture not made by the 
surgeon, the wound must be regarded as infected. If a wound is made by a 
dirty instrument through skin known to be unclean, it is proper that the skin 
about the puncture be sterilized, that the wound be enlarged, that foreign bodies 
be removed, that the wound be irrigated with an antiseptic solution, or be painted 
with pure carbolic acid, and be drained with a tube or a strip of gauze. Such 
treatment, though painful, and appearing unnecessarily severe or even cruel to 
the sufferer from a trivial puncture, is necessary, and may save the patient from 
serious illness or from death. Every deep puncture inflicted by an instrument 
not surgically clean, and every puncture inflicted by a nail, a splinter, a meat 
hook, a rusty pin, a tooth of a cat or dog, etc., must be regarded as grossly 
infected and must be treated by incision, sterilization, drainage, hot antiseptic 
fomentations, and rest. If the puncture is superficial and is made with a 
smooth pointed instrument like a needle, when the instrument was not grossly 
infected the parts may be dressed with hot antiseptic fomentations, but they 
should be inspected daily for evidence of infection and at the first sign of 
trouble an incision must be made. If a foreign body is retained in the tissue, 
it must be removed. 

Pure carbolic acid is a most efficient agent to sterilize a punctured wound. 

If an important cavity of the body has been invaded by a puncture, ex- 
ploratory incision is necessary (see Brain, Thorax, Abdomen). 

Stab-wounds. — Stab-wounds were formerly considered with punctured 
wounds, but Senn wisely places them in a class by themselves ("Practical 
Surgery"). Stab-wounds are inflicted by penetrating the tissues with 
a pointed or narrow instrument — for instance, a dagger, a knife, the blades 
of scissors, a bayonet, or a sword. Such wounds are narrow and very 
deep. A stab-wound may cause rapid death by penetration of a large blood- 



Gunshot-wounds 253 

vessel. Some great cavity of the body may be penetrated and internal hem- 
orrhage will then occur. The body may be transfixed by a sword or bay- 
onet. Bone is rarely injured unless the skull is perforated or the chest entered. 
In stab-wounds there is usually great hemorrhage and shock. 

Treatment. — Whenever possible, look at the instrument which did the 
damage and see if a piece is broken off. If no great cavity is entered, treat by 
general rules: arrest bleeding, react from shock, etc. The treatment of 
penetrating wounds of the abdomen, thorax, and cranium is discussed in the 
special sections. 

Gunshot-wounds. — Gunshot-wounds are contused or contused-lacerated 
wounds inflicted by materials projected by explosives. A bit of rock or a 
crowbar hurled by dynamite inflicts a gunshot-wound, as does a shell-frag- 
ment, a pistol-ball, small birdshot, a rifle-bullet, a flying cap, a piece of 
wadding, grains of powder, a buckshot, a fragment of metal broken off a 
shell, grapeshot and canister, or a cannon-ball. Injuries by shell-fragments, 
portions of a bursted boiler, pieces of masonry or wood, are either lacerated 
or punctured wounds, and need no special consideration here. In this article 
we treat of injuries caused by bullets and shot. 

The round bullet of the old-time musket being large, moving with com- 
parative slowness, and flattening easily, is very apt to lodge. When it is fired 
from close range and strikes the tissue at a right angle it produces a " punched- 
out" entrance wound. If the velocity is low or the impact is not at a right 
angle to the tissues, the entrance wound may "be formed of triangular flaps," 
the corners of which are inverted.* The entrance wound is surrounded by a 
bruised area. The track of the bullet is larger than the bullet, is so badly 
contused and lacerated that much tissue is devitalized, and the shaft of a bone 
is apt to be splintered if struck. If the ball emerges, the wound of exit is 
larger than the bullet and forms triangular and everted flaps (Stevenson). 
Healing by first intention will rarely occur. 

The conical or cylindrico-conoidal rifle-bullet has much greater velocity 
and penetrating power than the round bullet, hence it is more apt to perforate. 
The track of this bullet is less devitalized than is the track of the round ball 
and the surface is not so much contused. The wound of entrance is smaller 
than the bullet and is punched out or inverted. The wound of exit is larger 
than that of entrance, and is often everted. The bones are more seriously 
comminuted than by the round ball, and the fragments may be driven widely 
into the tissues (Stevenson); in fact, an explosive effect may occur at close 
range. Delorme lays it down as a rule that comminution of bone makes the 
wound of exit larger, and he asserts that a wound of exit larger in diameter 
than the thumb means that there is comminution of bone. 

At the present day the old round ball is very rarely used, the conical pro- 
jectile having taken its place. For the firearms of civilians, as a rule, the 
bullets are made of lead, hardened and shaped by compression, or hardened 
by an admixture with tin. The conical shape of the pistol-ball, the great 
velocity with which it is propelled and with which it rotates, and its hardness 
make it unlikely that at near range the bullet will only contuse and not enter 
the skin. It will almost always enter; it will often lodge and will not unusu- 
ally perforate; it is rarely deflected, and is not nearly so much flattened by 
*" Wounds in War," by Surg. -Colonel W. F. Stevenson. 



254 



Contusions and Wounds 



impact as is the softer round ball. A pistol-ball or a spent rifle-ball, however, 
may fail to enter the tissues, grazing the surface and inflicting a brush-burn, 
or simply contusing the part. A bullet may enter the tissues, a cavity, or an 
organ, and lodge there, causing a penetrating wound. It may enter and 
emerge, causing a perforating wound. The bullet may not enter alone, 
but may carry with it bits of clothing or other foreign bodies. This compli- 
cation is much more rare in injury by the conical bullet than by the round 
ball. 

The military surgeon deals with wounds inflicted by small, densely hard, 
conical projectiles, which are impelled at a great velocity and are carried to 
long distances. A rifle whose caliber is less than 0.35 inch is known as a 
small-caliber rifle. The best known modern rifles are the Lee-Metford, 
Krag-Jorgensen, Mauser, Mannlicher, Lebel, and Schmidt-Rubin. 

The old Springfield rifle, of a caliber of 
0.45 inch, projected a bullet with a velocity 
of thirteen hundred feet in a second. 

The Mannlicher rifle, of a caliber of 0.25 
to 0.32 inch, sends a bullet with a velocity of 
over two thousand feet a second. This bullet 
revolves with great velocity upon its own axis 
(two thousand times the first second) and is 
effective at several miles. 

The bullet of the modern rifle (Fig. 104) 
is conical, has a leaden core, and is hardened 
by being covered with a mantle or jacket of 
copper, steel, nickel, or of alloys of copper 
and nickel, or of copper, nickel, and zinc. 
The hard jacket is absolutely essential, as 
the speed of the projectile is so great that 
no soft bullet could take the rifling, frag- 
ments would be torn from it in the gun, and 
the grooves of the barrel wound soon fill 
up with metal, the gun becoming useless. 

The Lee-Metford bullet is elongated in 
outline, has a core of lead hardened with 
antimony, and the envelope is composed of 
an alloy of nickel and copper. 
The older projectile was apt to lodge; was often deflected in the tissues; 
was flattened out on meeting with resistant structures, such as bone or carti- 
lage (Fig. 105), and after flattening became larger and tore and lacerated 
the soft parts and comminuted the bone. 

The new projectile is apt to perforate, is rarely deflected, and is so hard 
that its shape is generally but little altered on meeting with resistant struc- 
tures, and hence it was thought that the new bullet would prove more humane 
than the old projectile, and inflict wounds which would be more easily treated, 
because the bullets would not lodge and because extensive damage would not 
be inflicted. This view has proved to a great extent correct. In many 
instances a modern bullet will make a clear track without laceration or com- 
minution. Senn, Xancrede, and other American surgeons in the Spanish- 




Fig. 103. — Mauser bullet-wound of 
chest : a. Wound of entrance ; b, point 
where bullet was extracted (Major 
Charles F. Kieffer, U. S. A.). 



Gunshot-wounds 



255 



American War say the modern projectile is humane at a range over fifteen 
hundred yards, as it generally penetrates cleanly, making a wound which heals 
by first intention. Sir Frederick Treves says " the Mauser bullet is a very 
merciful one. " In some instances, however, the small bullet pulpefies struc- 
ture for a considerable distance around the track of the ball by what is known as 
the explosive effect. This term does not mean that the bullet has exploded, 
but that its sudden impact against tissues has by waves of force caused exten- 
sive and distant damage, and often horrible and irreparable injurv. Explo- 
sive effects are seen most often at close range, when the velocity of the ball and 
the frequency of its rotation are most marked. A pistol-ball has no explosive 
action at all, and the old-time bullet possessed it only at very close range. The 
modern projectile always produces explosive effects up to five hundred vards. 
Up to thirteen hundred yards it produces them upon the skull and brain. 
At this distance a single small projectile may entirely destroy the cranium 
and brain (see Demosthen's studies of the action of the Mannlicher rifle). 
Explosive effects are noted at longer distances upon the liver, spleen, kidneys, 
and lungs, and upon hollow viscera 
containing fluid. 

At a distance of five hundred yards 
or less a bone will be shattered into 
many fragments. At a range of fifteen 
hundred or two thousand yards the 
bone will be cleanly perforated, usually 
without comminution. It is often ex- 
traordinary how little trouble follows 
a wound and how quickly healing oc- 
curs. This is due to the fact that 
the bullet is sterile when it reaches 
the tissue, and that foreign bodies 
are rarely carried in with it. In 
some observed cases there have been 
almost no symptoms after perforation 
of the lungs, in others after perforation of the abdomen or joints or skull. 
It is obvious that the humanity of the modern rifle is largely a matter 
of range. At a range of fifteen hundred yards or more it is a humane 
weapon. 

The wound of entrance is extremely small, and could be overlooked by a 
careless observer. It is usually circular, but may be triangular. The wound 
of exit is usually small, and may be round or may be a slit. If the injury was 
inflicted at close range, the wound of exit is large. This projectile theoretically 
does not flatten, but practically in many instances it does flatten a little, and 
in others its coat is torn off when it strikes hard bone at a distance of less 
than eighteen hundred yards (Fig. 106). Treves points out that if the bullet 
smashes a bone and lodges, the shell peels off from the core as a rule, and the 
bullet may be distorted or even broken into fragments. The bullet may lodge 
at long range, or if it hits a man after bounding from a stone. In Cuba 10 
per cent, of the wounded suffered from lodged bullets. The old-style bullet 
rarely causes much primary hemorrhage, as the vessels as well as the nerves 
and tendons are usually pushed aside rather than cut. Hence secondary hem- 




123 4 

Fig. 104.— 1, End view of 2, the Krag-Jor- 
gensen bullet ; 3, Mauser bullet ; 4, Lee-Metford 
bullet, used bv the United States Navy. 



256 



Contusions and Wounds 



orrhage is common because of contusion of the vessel-walls. The modern bul- 
let cuts rather than pushes aside the vessels. Hence primary hemorrhage is pro- 
fuse if a large vessel is struck, and may prove fatal. The modern bullet rarely 
lodges and is rarely deflected. Skin is usually split by it. Fascia and muscle 
are usually much damaged, but in a transverse wound of muscle the fibers 
may be separated rather than destroyed (Conner). The effects of the mod- 
ern bullet were determined by careful study and experiment; by an in- 







Fig. 105. — Deformation of leaden bullets (natural size) (Seydel). 








Fig. 106.— Deformation of small-caliber jacketed bullets (after Bruns). 



vestigation of the wounds in the Chitral Expedition and of wounds inflicted 
by accident or with homicidal or suicidal intent; by experiments: firing 
through boxes filled with wet sand; firing into thick oak; firing at cadavers at 
fixed distances with reduced charges (La Garde) ; firing at corpses and at live 
horses with service-charges (Demosthen). Nancrede cautions us to remember 
that experiments upon the cadaver, employing reduced charges and standing 
at fixed distances, are uncertain in their provings. " The difference between 
the velocity of rotation and angle of incidence with reduced charges at fixed 
distances and service-charges at actual distances is marked. The tension of 
living muscles and fasciae, as compared with dead tissues, and the physical 
change of the semi-liquid fat of adipose tissue and medulla to a more solid 
condition by the loss of animal heat, influence the results."* 

All theoretical conclusions have been put to the test in the Spanish-Amer- 

* Nancrede upon "Gunshot -wounds," in Park's "Surgery by American Authors." 
For information upon wounds by the modern firearm, see recent reports of Surgeon-Gen- 
eral of the United States Army; Demosthen's study of the wounds inflicted by the Mann- 
licher rifle; Professor Conner, in Dennis's "System of Surgery;" Forwood, in "The Inter- 
national Text-Book of Surgery;" the elder Senn on "Medico-Surgical Aspects of the 
Spanish-American War;" Sir Frederick Treves, in the Lancet, May 12, 1900; Discussion 
in the British Medical Association, 1899; reports of Mr. G. H. Makins and Clinton T. 
Dent; Francis G. Abbott on the "Surgery of the Graeco-Turkish War," in Lancet, Jan. 
14, 1899; editorial in Boston Med. and Surg. Jour., May 4 and May 9, 1899; a study of 
"Gunshot Injuries by the Rifles of Reduced Caliber," by Louis A. La Garde, in Boston 
Med. and Surg. Jour., Nov. 1, 1900; J. Lynn Thomas, in Lancet, Nov. 3, 1900, and 
reports in various journals on wounds in the Russo-Japanese War. 



Symptoms of a Gunshot-wound 257 

ican War, the South African War, the taking of Pekin, and the Russo-Japanese 
War, and preconceived opinions have to a great extent been confirmed. The 
effect of the bullet at close range was observed in the marines killed at Guan- 
tanamo, in persons killed during the Milan riots, and in many instances in 
South Africa, China, and Port Arthur. 

It has been found that the modern small-caliber bullet, unless it strikes 
a vital part or a large bone, lacks ''stopping power," and in warfare with 
savages the bullet must have stopping power, or the wounded man will con- 
tinue to fight and charge. Civilized men will usually stop when hit, savages 
often will not; hence, in warfare with barbarous people the ordinary bullet 
must be modified. In the Dumdum bullet a portion of lead at the apex of 
the projectile is left uncovered, and the bullet when it strikes spreads out — 
"mushrooms," as it is called — and inflicts an extensive wound which "stops" 
the most ferocious and fanatical. German surgeons denounce such bullets as 
inhumane, but Stevenson and other English surgeons say that the Dumdum 
bullet is more humane than the Snider or Martini-Henry. The name Dum- 
dum comes from the ordnance factory, near Calcutta, where bullets of this 
character were first made. 

Wounds by Cannon-balls. — A cannon-ball weighing five or six pounds 
may be imbedded in tissues. A ball or shell-fragments may tear off a limb 
or lacerate it extensively. In some cases of injury by spent balls the bone is 
dotroyed and the muscles disorganized while the skin is intact. 

Wounds by Small Shot. — The degree of injury is in direct ratio to the 
nearness of the individual to the gun when the discharge took place, to the 
size and number of the shot, and to the charge of powder. Single shot may 
bruise the surface or may enter the tissues. When many shot enter together 
they strike as a solid body. Single shot are usually deflected from vessels 
and nerves, and rarely lodge in bone, but rather flatten on its surface. Numer- 
ous shot entering together at close range produce extensive burns and fearful 
lacerations and inflict damage which is often irreparable. Pieces of clothing 
or other foreign bodies may be carried into the wound with the shot. 

Blank Cartridge Injuries. — These injuries only occur at close range. 
They consist of burns and lacerations and frequently a wad is lodged in the 
tissues. Tetanus is liable to follow these injuries. 

Symptoms of a Gunshot-wound. — Hemorrhage is often considerable, 
but ceases spontaneously unless a large vessel has been divided. If hemor- 
rhage is profuse, the constitutional symptoms of hemorrhage exist. These 
symptoms are of great importance in abdominal wounds. A pistol-ball 
rarely causes severe primary hemorrhage, because it will not often penetrate 
a large artery. It is apt to push aside a vessel, and secondary hemorrhage 
is not unusual. Even if a large vessel is wounded and a succession of 
violent hemorrhages occur, a man may live for several days. Secondary 
hemorrhage may follow a gunshot-wound because of contusion of vessels or 
of infection. 

Pain is often not noticed at first, especially if the injured individual was 
greatly pre-occupied or excited. There may be a feeling of numbness, but 
there is usually a dull or stinging pain. If a large nerve is injured, there may 
be violent pain. Even trivial gunshot-wounds frequently produce profound 
shock, and yet it may happen that severe wounds may be accompanied by 



258 Contusions and Wounds 

but slight shock. In most gunshot-wounds of the brain, abdomen, and 
spinal cord the shock is very great. * 

General Considerations as to Treatment. — The dangers are shock, 
hemorrhage, and infection. Bullets are aseptic when they enter a part, and 
if infection is not inserted in the track of the ball the wound will in most 
instances heal kindly. " The fate of a wounded man is in the hands of the 
surgeon who first attends him " (Nussbaum). The danger of a wound depends 
upon the size and velocity of the bullet, the part struck, "and the degree 
of asepsis observed during the first examination and dressing" (Nancrede). 
The rules of treatment are: bring about reaction, arrest hemorrhage, pre- 
serve asepsis, and, in some cases, remove the ball. Always notice if a wound 
of exit exists. It is a good plan, when endeavoring to determine the extent 



||||pa 



Fig. 107. — Nelaton's bullet probe. 



•^ n=T: 11lirP gri " i8 ^'^'"" g 




Fig. 108. — Senn's bullet probe. 



Fig. 109.— Fluhrer's aluminum gravitation probe (natural size, except the length, which is twelve 

inches). 

of injury, to put the parts in the position they were in when the injury was 
inflicted. We should try to ascertain the size and nature of the weapon, and 
the range at which it was fired. Examine the clothing to see if any fragments 
are missing and could have been carried in. Such fragments render sepsis 
almost inevitable. The surgeon must not feel it his duty to probe in all cases. 
In many cases it is better not to probe at all. Explore for the ball when sure 
that it has carried with it foreign bodies; when its presence at the point of 
lodgment interferes with repair; when it is in or near a vital region (as the 
brain) ; and when it is necessary to know the position of the .bullet in order 
to determine the question of amputation or resection. If the wound is large 
enough, the finger is the best probe. 

Fluhrer's aluminum probe is a valuable instrument (Fig. 109). It is 
employed especially in brain-wounds, and is allowed to sink into the track of 
the ball by the influence of gravity after the part has been placed in a proper 
position. If a lead bullet is deeply imbedded, it is possible to distinguish the 
hard projectile from a bone by inserting the asepticized stem of a clay pipe, a 
bit of pine wood, or Nelaton's porcelain-headed probe (Fig. 107). On any^ 

* If the skin about some part of the wound is scorched and if powder grains are 
imbedded in it the weapon was fired at close range, probably within three feet. If the 
skin is not scorched and powder grains are not imbedded, we are not justified in contend- 
ing that the bullet was not fired at a very near range. For the medico-legal questions 
determined by blackening, burning, and tattooing of the wound edges, consult a work on 
Legal Medicine. 



Locating and Extracting Bullets 259 

one of these appliances lead will make a black mark. No such test can 
be applied to a modern bullet, for this has a hard metal jacket, and will not 
make a black mark on a white substance. 

Though Nelaton's probe will not show the difference between a hard 
projectile and bone, it is a valuable instrument to follow the track of a wound. 
The porcelain head ought to be larger than it is usually made — in fact, it 
should be nearly the size of the bullet (Senn) (Fig. 108). 

In passing a probe use no more force than in passing a catheter (Senn). 

The induction balance of Graham Bell has been employed to determine 
the situation of a bullet. The bullet may be located by Girdnefs telephonic 
probe. In order to construct this instrument, take a telephone receiver, fasten 
one of the wires to a metal plate and the other one to a metallic probe. Mois- 
ten a portion of the patient's body and place the metal plate in contact with it. 
The surgeon places the receiver to his ear and inserts the probe into the wound. 
If the probe strikes metal, a click is heard with distinctness. A bullet may 
be located by LilienthaVs probe. This apparatus consists of a mouth-piece, 
two insulated copper wires, and a probe. The mouth-piece is composed of 
two plates, one of copper and one of zinc, which are applied to the sides of the 
tongue. An insulated wire runs from each plate and into the metal probe. 
The tip of the probe is composed of two or four pieces of metal, is separated 
from the shank by a washer of rubber, and is attached to the wires. The 




Fig. no. — Bullet-forceps. 

operator closes the teeth upon the mouth-piece, and inserts the probe into the 
wound. If the probe touches the bullet, a distinct and continuous metallic 
taste is appreciable. 

The best means of discovering a bullet is to use the fluoroscope or take a 
skiagraph. In order to locate it accurately, view it through a series of squares, 
insert guide-pins, or, better than either of these plans, employ Sweet's appa- 
ratus. Bullets are readily seen by the fluoroscope in the superficial soft parts, 
and are discovered in deeper structures (bone, abdomen, lung, brain, etc.) 
by taking skiagraphs. 

In extracting the ball use very strong forceps (Fig. no). The old Amer- 
ican bullet-forceps is useless for the extraction of the hard-jacketed ball, as the 
points will not penetrate and the instrument will not hold. 

If hemorrhage is severe in a gunshot-wound, enlarge the wound, find the 
bleeding vessel, and tie it. Before handling a gunshot-wound asepticize the 
parts about it and irrigate the wound with hot sterile salt solution. In some 
situations a wound should be drained with a short tube or a bit of iodoform 
gauze; in other regions this is unnecessary. The dressing should be anti- 
septic. Primary union rarely takes place after a wound inflicted by a pistol- 
ball or an ordinary rifle-ball, because of the inevitable necrosis of damaged 
tissue in the track of the ball, but in some cases it can be obtained. Primary 



260 



Contusions and Wounds 



union is frequent after injury by the small hard-jacketed modern projectile. 
Healing begins in the depths of the wound and extends toward the wound of 
entrance, or, if there be also a wound of exit, toward both. Radical opera- 
tions may be demanded: laparotomy, trephining, rib-resection, joint-resec- 
tion, or amputation. 

Amputation is sometimes demanded because of great injury to the soft 
parts (as by a shell-fragment), the splintering of a bone, injury of a joint, 
damage to the chief vessels or nerves, or the destruction of a considerable 
part of a limb. Perform a primary amputation if possible, and make the flaps 
through tissue that will not slough. In civil practice, with careful antisepsis, 
more questionable tissue can be admitted into a flap than in military practice, 
where transportation will become necessary and antisepsis may be imperfect 
or wanting. It has been shown in recent years that even when a large joint 
has been perforated by a small hard-jacketed projectile, amputation or resec- 
tion is rarely required if the wound was treated aseptically from the begin- 
ning. 

Prevention of infection in wounds inflicted in war is of great importance. 
In warfare at the present day an attempt is made to limit the death-rate from 
gunshot-wounds by protecting them from infection at an early period after 




Fig. in. — Cartridge belt with first-aid package sewed on inner surface. 

the accident. Esmarch offered a suggestion, which has been adopted in the 
armies of all civilized countries. Every soldier carries a package which con- 
tains antiseptic dressings, and at the first opportunity after the infliction of a 
wound, if possible on the field, these dressings are applied by the soldier or 
by a comrade (for even the privates are instructed in the application), or by 
an ambulance man. If not applied on the field, they are applied at the first 
dressing-station by a surgeon or a hospital steward. Senn considers Esmarch's 
package too cumbrous.* He suggests a package containing half an ounce 
of compressed salicylated cotton. In the center of this cotton is an antiseptic 
powder (2 gm. of boric acid and 0.5 gm. of salicylic acid). The cotton is 
wrapped in a triangular gauze bandage. A safety-pin is placed in the bandage 
and the entire bundle is wrapped in gutta-percha tissue (Fig. in). Senn says 
the triangular bandage is sufficient to hold a dressing in place, and it can be 
assisted by utilizing the gunstrap, safety-belt, or articles of clothing, f (For 
gunshot-wounds of special structures, see Bones, Joints, Abdomen, Brain, etc.) 
When a wound has been inflicted by a blank cartridge, the surface should be 
cleansed, the wound irrigated, foreign bodies removed, the parts sterilized, and 

* Jour. Am. Med. Assoc, July 13, 1895. 

t Senn, in Jour. Am. Med. Assoc, July 13, 1895. 



Malignant Edema or Gangrenous Emphysema 261 

dressed with hot antiseptic fomentations. In some cases the wound should be 
enlarged; in some, powder grains should be removed from the skin. In view 
of the danger of lockjaw and because tetanus bacilli do not multiply when 
exposed to oxygen, some surgeons advocate keeping such wounds exposed to 
the air throughout the treatment. After an injury with shot, bleeding should 
be arrested, the parts should be cleansed, bits of clothing and other such 
foreign bodies should be removed, and antiseptic dressings should be applied. 
It is not necessary to remove the shot unless they are doing harm or unless 
they lie just beneath the skin. 

Poisoned wounds are those into which some injurious substance, chem- 
ical or bacterial, was introduced. This poison may be microbic and capable 
of self-multiplication, or it may be chemical, and hence incapable of multi- 
plication. There are three classes of poisons: * (1) mixed infection, as septic 
wounds, dissection-wounds, and malignant edema; (2) chemical poison, 
such as snake-bites and insect-stings; and (3) infection with such diseases 
as rabies, glanders, etc. 

Septic wounds are those which putrefy, suppurate, or slough. Septic 
wounds should be opened freely to secure drainage, and hopelessly damaged 
tissue should be curetted or cut away. The wound should be washed with 
peroxid of hydrogen and then with corrosive sublimate, dusted with iodoform 
or orthoform, either drained with a tube or packed with iodoform gauze, and 
dressed with hot antiseptic fomentations. The part must be kept at rest and 
internal treatment should be stimulating and supporting. If lymphangitis 
arises, the skin over the inflamed vessels and glands is to be painted with iodin 
and smeared with ichthvol, and quinin, iron, and whiskey are given internally. 
The temperature is watched for evidence of general infection or intoxication. 
The patient must be stimulated freely, nourishing food is given at frecjuent 
intervals, pain is allayed by anodynes if necessary, and sleep is secured. 

Dissection=WOunds are simple examples of infected wounds, and they 
present nothing peculiar except virulence. They affect butchers, cooks, 
surgeons who cut themselves while operating on infected areas, those who 
make post-mortems, and those who dissect. A dissection-wound inflicted 
while working on a body injected with chlorid of zinc possesses but few 
elements of danger unless the health of the student is much broken down. 
If a wound is simply poisoned with putrefactive organisms, there is rarely 
serious trouble. Post-mortems are peculiarly dangerous when the subject 
has died of some septic process. When a wound is inflicted while dissecting, 
wash it under a strong stream of water, squeeze, and suck it to make the blood 
run, lay it open if it be a puncture, paint it with pure carbolic acid, and dress 
it with iodoform and hot antiseptic fomentations. Trouble, of course, may 
follow, but often it is only local, and a small abscess forms. It should be 
treated by hot antiseptic fomentations and early incision. Occasionally 
lymphangitis arises, adjacent glands inflame, and constitutional symptoms 
arise. It is rarely that true septicemia or pyemia arises unless the wound 
was inflicted while making a post-mortem upon a person dead of septicemia 
or while operating on a septic focus. If glands enlarge and soften, it may be 
necessary to remove them surgically. 

Malignant edema or gangrenous emphysema arises most commonly 

* "American Text-Book of Surgery." 



262 Contusions and Wounds 

after a puncture. It is due to a specific bacillus which produces great edema. 
The emphysema which soon arises is due to mixed infection with putrefactive 
organisms. Pus does not form, but gangrene occurs. The disease is identical 
with one form of traumatic spreading gangrene (page 174). 

Symptoms. — The symptoms are identical with those of traumatic spread- 
ing gangrene with emphysema. 

There is a rapidly spreading edema, followed by gaseous distention of the 
tissues and by gangrenous cellulitis. The zone of edema is at the margin of 
the emphysema, and the process spreads rapidly. The emphysematous zone 
crackles when pressed upon. The area of edema is covered with blebs which 
contain thin, putrid, reddish matter, and the skin becomes mottled. If a 
wound exists, the discharge will be bloody and foul. If incisions are made, 
a thin, brown, offensive liquid flows out. High fever rapidly develops, the 
patient becomes delirious, and often coma arises. In most cases death ensues 
in from twenty-four to forty-eight hours. 

Treatment. — If malignant edema affects a limb after a severe injury 
amputate at once, high up. If it affects some other part or begins in a limb 
after a trivial injury, make free incisions, employ hot, continuous antiseptic 
irrigations or the hot antiseptic bath, and stimulate freely (page 175). 

Stings and Bites of Insects and Reptiles: Stings of Bees and 
Wasps. — A bee's sting consists of two long lances within a sheath with which 
a poison-bag is connected. The wound is made first by the sheath, the poison 
then passes in, and the two barbed or twisted lances, moving up and down, 
deepen the cut. The barbs on the lances make it difficult to rapidly with- 
draw the sting, which may be broken off and remain in the flesh. Besides 
bees, hornets, yellow jackets, and other wasps produce painful stings. The 
sting of a wasp is rarely broken off in the tissues because the beards on the 
darts are shorter and hence the sting is not so firmly fixed in the flesh, and also 
because these insects are more rapid and nimble in their actions. Stings of 
bees and wasps rarely cause any trouble except pain and swelling. In some 
unusual cases a bee-sting is fatal; persons have been stung to death by a great 
number of these insects. 

Symptoms. — If general symptoms ensue, they appear rapidly, and con- 
sist of great prostration, vomiting, purging, and delirium or unconsciousness. 
These symptoms may disappear in a short time, or they may end in death 
from heart-failure. Stings of the mouth may cause edema of the glottis. 

Treatment. — To treat a bee-sting, extract the sting with splinter forceps 
if it has been broken off and is visible in the wound. If it is not visible, 
squeeze the part lightly in order to expel it, or at least expel the poison. Pres- 
sure may be most satisfactorily made by means of the barrel of a key. The 
poison is counteracted by touching with ammonia or washing the part in 
ammonia-water, touching with pure carbolic acid, painting with tincture of 
iodin, or soaking in a strong solution of common salt or carbonate of sodium. 
The part may be dressed with lead-water and laudanum, a solution of washing- 
soda, or a solution of common salt. If constitutional symptoms appear, 
stimulate. 

Other Insect=bites and Stings.— The mandibles of a poisonous spider 
are terminated by a movable hook which has an opening for the emission of 
poison. The bite of large spiders is productive of inflammation, swelling, 



Snake-bites 263 

weakness, and even death. The bite of the poisonous spider of New Zealand 
produces a large white swelling and great prostration; death may ensue, or 
the victim may remain in a depressed, enfeebled state for weeks or even for 
months. The tarantula is a much-dreaded spider. The scorpion has in its 
tail a sting. The sting of the scorpion produces great prostration, delirium, 
vomiting, diaphoresis, vertigo, headache, local swelling, and burning pain, 
followed often by fever and suppuration, and occasionally even by gangrene, 
but it is rarely fatal. Centipedes must be of large size to be formidable to 
man, and the symptoms arising from their stings are usually only local. 

Treatment. — Tie a fillet above the bitten point; make a crucial incision, 
favor bleeding, and paint the wound with pure carbolic acid or some caustic 
or antiseptic (if in the wilds, burn with fire or gunpowder) ; dress antiseptically 
if possible, and stimulate as constitutional symptoms appear. Slowly loosen 
the ligature after symptoms disappear. Chloroform stupes and ipecac poul- 
tices are recommended; also puncture with a needle and rubbing in a mix- 
ture of 3 parts of alcohol and 1 part of camphor (Bauerjie). 

Snake=bites. — The poisonous snakes of America comprise the copper- 
heads, water-moccasins, rattlesnakes, and vipers. The cobra of India is a 
deadly reptile. In some countries great numbers of people and the lower 
animals are killed by poisonous serpents. In India during 1898, 21,921 
persons and at least 80,000 cattle were killed by snakes ("Brit. Med. Jour.," 
Nov. 25, 1899). It used to be taught that there is no essential difference in 
the action of venoms of different varieties of snakes and that the venom of 
an Indian cobra is practically identical with the venom of an American rattler, 
any apparent difference in action depending upon difference in toxic power 
and the different dose of poison introduced. We now know that there are 
essential differences in venoms (Leonard Rogers, in "Lancet," Feb. 6, 1904). 
The natural toxic power of the poison varies in different species and also in 
different members of the same species. Poison injected into a vein may prove 
almost instantly fatal. The poison is not absorbed by the sound mucous 
membranes. Poison is harmless when given by the mouth and swallowed, but 
if directly introduced into the intestine of an animal it is certainly fatal. The 
pancreatic ferment destroys the toxic power of the venom (R. H. Elliot, in 
"Brit. Med. Jour.," May 12, 1900). The venom is discharged through the 
hollow fangs of the reptile, having been forced out by contractions of the 
muscles of the poison-bag. In most varieties of snakes the teeth lie along the 
back of the mouth and are only erected when the reptile strikes. Snake- 
poison is a thin, greenish-yellow, turbid, sterile fluid, of acid reaction and of 
a distinctive odor. The two chief poisonous principles are called venom- 
peptone and venom-globulin (Gustave Langmann, "Medical Record," 
Sept. 15, 1900). 

Symptoms. — Rogers ("Lancet," Feb. 6, 1904) divides poisonous snakes 
into two classes: the colubrines (of which the cobra is an example) and the 
viperines, which are not so poisonous (this class includes rattlesnakes and puff 
adders). Colubrine venom, according to this observer, causes paralysis of 
the respiratory center and of the motor end organs of the phrenic nerves, 
destruction of red blood-corpuscles, lessened coagulability of blood, and death 
by respiratory paralysis. Viperine venom causes paralysis of the vaso-motor 
center, great destruction of red corpuscles, some viperine venoms may cause 



264 Contusions and Wounds 

thrombosis, and death from any one of them is due to vaso-motor 
paralysis. The venom of some snakes, Rogers says, contains a mix- 
ture of the above-mentioned venoms (among such snakes are the Aus- 
tralian colubrines and the American pit adders). The mortality from 
snake-bites varies. The mortality in India from cobra bites is about 25 
per cent. (Sir Joseph Fayrer). The mortality in America from rattlesnake 
bites is about the same. The local symptoms are: pain, soon becoming 
intense; mottled swelling of the bitten part, which swelling may be enormous, 
and which is due to edema and extravasation of blood, and assumes a pur- 
puric discoloration. The bite oj a cobra produces inflammation and marked 
spreading edema. It may be recovered from without symptoms or with 
trivial symptoms it may induce profound systemic involvement. The gen- 
eral symptoms begin in a comparatively few minutes. The coagulating 
power of the blood is lost, there is great destruction of red corpuscles. The 
patient is terror-stricken and soon becomes unable to stand because of weak- 
ness of the legs. Glosso-laryngeal paralysis arises, and talking and swallowing 
become impossible. There is a profuse flow of saliva, perhaps nausea and 
vomiting. The patient may be dull mentally but is not unconscious. The 
paralysis becomes widespread, and finally the diaphragm and respiratory 
center become involved, and death occurs from respiratory paralysis. Arti- 
ficial respiration may prolong life for hours (Sir Joseph Fayrer). Bad cases 
usually die in three or four hours, but life may last for many hours. A rattle- 
snake bite produces severe pain and mottled swelling from blood extravasation. 
In some cases there is enormous swelling from edema and blood; the discol- 
oration in such a case is purpuric. The blood of the victim quickly undergoes 
hemolysis and loses the power of coagulation. It was previously stated that 
in laboratory experiments it has been shown that viperine poison may produce 
thrombosis, but it does not do so in man, as it contains a very small amount 
of the coagulating element (Rogers). Extravasations of blood occur in serous 
and mucous membranes and in the skin, petechial spots frequently arising 
upon the cutaneous surface. There may be free bleeding from mucous sur- 
faces and great extravasation beneath the conjunctivae. These blood extrav- 
asations are due, according to Flexner, to destruction of vascular endothelium. 
General symptoms begin in from a few minutes to several hours. The symp- 
toms are those of profound shock, possibly with delirium, the vaso-motor center 
being exhausted and finally paralyzed. There is usually muscular twitching, 
convulsions, and finally paralyses are noted in most cases (pharyngeal palsy, 
paraplegia, and ascending paralysis). There maybe complete consciousness, 
or there may be lethargy, stupor, or coma. Death may occur in about five 
hours, but, as a rule, it is postponed for a number of hours. If death is deferred 
for a day or more, profound sepsis comes upon the scene, with glandular 
enlargement, suppuration, and sometimes gangrene. 

Treatment. — Cases of snake-bite must, as a rule, be treated without 
proper appliances. The elder Gross was accustomed to relate in his lectures 
how he had seen an army officer blow off his finger with a pistol the moment 
after it was bitten by a rattlesnake, and thus escape poisoning. In general, 
the rules are to twist several fillets at different levels above the bite, to excise 
the bitten area, to suck or cup it if possible, and to cauterize it with pure acid 
or by heat. An expedient among hunters is to cauterize by pouring a very little 



Anthrax 265 

gunpowder on the excised area and applying a spark, or by laying a hot ember 
on the wound. When a hot iron is available, use it. The fillets are not to be re- 
moved suddenly, and they had best be kept on for some time. Remove the high- 
est constricting band first; if no symptoms come on after a time, remove the 
next, and so on; if symptoms appear, reapply the fillet. Some surgeons inject in 
many places about the wound a few drops of a 10 per cent, watery solution of 
chlorid of calcium. It is taught by others that if a man is bitten by a large 
and deadly snake, the surgeon, if one is at hand, should at once amputate 
well above the bite.* Wynter Blyth pointed out that permanganate of potas- 
sium mixed with an equal weight of cobra venom renders the venom inert. 
A number of surgeons have treated snake bites by injecting in and about the 
wound a 1 per cent, solution of permanganate of potassium, but this plan is in- 
efficient. Rogers ("Lancet," Feb. 6, 1904) says we should tie a fillet around 
the limb above the bitten part, take a knife and enlarge the wound and rub 
in crystals of permanganate. Whatever local treatment is employed stimu- 
lants are to be given and large doses of alcohol are very generally relied upon. 
Some give strychnin hypodermatically, others ether, others digitalis. Hal- 
ford, of Australia, advocated the intravenous injection of ammonia (10 n\ 
of strong ammonia in 20 n\ of water). Adrenalin as given in shock, is indi- 
cated if the vaso-motor center is becoming paralyzed, and auto-transfusion 
and external heat are also indicated. If the respiration is failing artificial 
respiration and oxygen inhalation are required. Attempts are being made 
to obtain a curative serum. Animals can be rendered immune by giving 
them at first small doses of the poison and gradually increasing the amount 
administered. It is asserted that the serum of immune animals will cure a 
person bitten by a venomous snake. Cures have been reported after the use 
of Calmette's antivenene serum. The dose is from 10 c.c. to 20 c.c. hypoder- 
matically, repeated if necessary in three or four hours. It seems certain, 
however, that no single serum can antidote the venom of all varieties of 
serpents (A. T. F. Macdonald, of Australia), and it has been shown that, 
though Calmette's antivenene is antagonistic to colubrine venom, it is inert 
against viperine venom (Rogers). Again, as Rogers says, it deteriorates 
quickly in hot climates and is seldom on hand when wanted. 

The poisonous lizard (Gila monster) can kill small animals, but it 
is not believed that its bite would prove fatal to man. 

Anthrax (Malignant Pustule, Charbon, Wool-sorters' Disease, 
Milzbrand, or Splenic Fever) is a term used by some as synonymous with 
ordinary carbuncle, but it is not here so employed. It is a specific contagious 
disease resulting from infection with the bacillus of anthrax. Animal anthrax is 
particularly common in the East and in Russia, and is frequently met with 
in Germany, Italy, and South America. In some regions so many cases 
arise year after year that the region obtains an evil notoriety. It is stated 
that in Novgorod, Russia, in four years, "56,000 horses, cattle, and sheep, 
and 528 men are reported to have perished from anthrax" (Frank S. Billings, 
in "Twentieth Century Practice"). It is a rare disease in the United States. 
In Philadelphia cases occasionally arise in workers in the woolen mills. 
The author has seen three cases of human anthrax, two of which arose in 
Philadelphia and one in New Jersey- Herbivora are most liable, next 
* Charters James Symonds, in " Heath's Dictionary of Practical Surgery." 



266 Contusions and Wounds 

omnivora, but carnivora seldom suffer. Anthrax, as met with in man, 
is a disease contracted in some manner from an animal with splenic 
fever. It may be contracted by inoculation by working around diseased 
animals, by handling or tanning their hides or by sorting their hair or 
wool; brush-makers, spinners, workers in horn, and combers, rag sorters, 
veterinary surgeons, clippers, stockmen, farmers, and butchers may become 
inoculated; it may be conveyed by eating infected meat or by drinking infected 
milk. Flies may carry the poison. Inhalation of poisoned dust may infect 
the lungs. Catgut ligatures may be contaminated and carry the poison. 
Many attempts, not altogether satisfactory, have been made to render animals 
immune (Pasteur, Woolbridge, Hankin). Certain organisms are antagonistic 
to anthrax (the streptococcus of erysipelas, the pneumococcus, the micrococcus 
prodigiosus, and the bacillus pyocyaneus). 

Forms of Anthrax. — There are two forms of the disease — external and 
internal. Internal anthrax may be intestinal from eating diseased meat or 
pulmonary from inhalation of poisoned dust. Intestinal anthrax arises only 
when the bacilli in the meat contain spores. Koch and others have pointed 
out that the non-sporulating bacteria are destroyed by the gastric juice. 
External anthrax may be anthrax carbuncle or anthrax edema. Anthrax 
carbuncle or malignant pustule appears on an exposed portion of the body, 
especially the hand or fingers, in over 80 per cent, of cases of external anthrax. 
I saw one upon the temple. It appears in from twenty-four hours to six days 
after inoculation, and presents an itching, burning papule with a purple center 
and a red base; in a few hours the papule becomes a vesicle which contains 
bloody serum and the tissues about the papule become swollen, reddened, and 
indurated. The vesicle bursts and dries, the base of it swells and enlarges, 
other vesicles appear in circles around it, and there is developed an " anthrax 
carbuncle," which shows a black or purple elevation with a central depression 
surrounded by one or more rings of vesicles. The surrounding tissues become 
purple, and great edema may spread widely, the vesicles grow very large and 
new vesicles form, and gangrene may occur. Pain is trivial or absent. Lym- 
phatic enlargements occur but pus does not form. Within forty-eight hours 
after the pustule begins micro-organisms usually appear in the blood. The 
constitutional symptoms may rapidly follow the local lesion, but may be de- 
ferred for a week or more. The patient feels depressed, has obscure aches and 
pains, and is feverish, but usually keeps about for a short period. After a 
time he is apt to develop rigors, high irregular fevers, sweats, acute fugitive 
pains, diarrhea, delirium, typhoid exhaustion, dyspnea, cough, and cyanosis. 
The carbuncle of anthrax is distinguished from ordinary carbuncle by the 
central depression, the adherent eschar, the absence of pain, tenderness, and 
suppuration of the first, as contrasted with the elevated center, the multiple 
foci of suppuration and sloughing, and the more severe pain usual in the 
second. If anthrax has a visible lesion and the constitutional symptoms are 
slight or absent the chance of cure is good. In cases which get well a line 
of demarcation forms about the pustule and the gangrenous area is rather 
rapidly cast off, a granulating surface remaining. 

Anthrax Edema. — An area of edema surrounds a malignant pustule and 
often spreads widely, but in cases of external anthrax without a pustule there 
is edema alone. This lesion occurs in connective tissue, especially loose 



Treatment of External Anthrax 267 

tissue. It is a spreading, livid edema, with an ill-defined margin. There 
is no pain and usually no vesication and no fever. In severe cases, however, 
there is fever, vesicles form, and gangrene may arise. Anthrax edema differs 
from cellulitis in the absence of pus formation, and from malignant edema 
by the less disposition to result in gangrene. Two of the cases I have seen 
were anthrax edema. In Horwitz's case in the Philadelphia Hospital the 
forearm, arm, and shoulder were enormously edematous. In Keen's case 
in the Jefferson College Hospital the forearm and arm were edematous. 

Prognosis. — The usual estimate of the death rate from external anthrax- 
is from 25 to 30 per cent. If upon the face the prognosis is much worse than 
if upon the extremities, and if upon the upper extremity worse than if upon 
the lower. The death rate has been notably reduced by modern treatment 
and under serum treatment is said to be but little over 6 per cent. 

Pulmonary anthrax and intestinal anthrax have been regarded as in- 
variably fatal, but vastly better results may be looked for hereafter. 

Treatment of External Anthrax. — If a person is wounded by an object 
suspected of carrying the infection, cauterize the wound with the hot iron. A 
sufferer from anthrax must be isolated in a well- ventilated room. All dress- 
ings are to be burned, all discharges asepticized, and after the removal of the 
patient the bed-clothes are burned and the room disinfected. A malignant 
pustule should be entirely excised, and the wound mopped out with pure 
carbolic acid or burned with the hot iron. If there is an extensive area of 
edema it should be freely incised at several points. The area about the excised 
pustule should be injected with a 5 per cent, solution of carbolic acid. The 
wound and the edematous area should be dressed with hot antiseptic fomen- 
tations, and, if dealing with an extremity, a splint is applied. Excision 
should be practiced even when glands are enlarged, but it will prove 
ineffectual, as a rule, if organisms are present in the blood. When excision 
cannot be performed make crucial incisions through the lesion, mop the 
wounds with pure carbolic acid, and inject about and in the pustule car- 
bolic acid (1 : 20) every six hours until the disease abates or toxic symp- 
toms appear. Dress the part as directed above. In a successful case the 
adherent eschar is finally separated by the influence of the fomentations. 
Davaine advised the following plan: Inject the pustule and the tissues about 
it at many points every eight or ten hours with 1 part of tincture of iodin 
diluted with 2 parts of water or with a 10 per cent, solution of carbolic acid, 
or with a 0.1 per cent, solution of corrosive sublimate. Dress with wet anti- 
septic gauze and apply an ice-bag. Personally I would not use an ice-bag 
on an area of infection but would prefer heat. In anthrax edema inject a 
5 per cent, solution of carbolic acid into the apparently sound skin and sub- 
cutaneous tissue just above the margin of the edema and repeat the injections 
every six hours. Make free multiple incisions in the edematous area carry- 
ing each incision down to the deep fascia. Dress with hot antiseptic fomen- 
tations and if dealing with a limb apply a splint. In Keen's very severe 
case of anthrax edema, this treatment was carried out by George J. 
Schwartz and recovery followed. Constitutional treatment in anthrax edema 
or malignant pustule must be sustaining and stimulating. Maffucci gives 
carbolic acid internally, and also uses it externally. Davies-Colley uses ipecac 
locally and gives gr. v by the mouth every four hours. Statistics indicate 



268 Contusions and Wounds 

that the serum treatment is of the greatest value. The material is known 
as Sclavo's serum; it is obtained from the immunized ass, and it was in- 
troduced into practice in 1897. It is perfectly harmless and may be given in 
a vein or subcutaneously. Sclavo injects 40 c.c. in different regions of the wall 
of the abdomen. If improvement is not obvious in twenty-four hours the dose 
is repeated. Intravenous injection is reserved for severe cases, the dose being 
10 c.c. into a subcutaneous vein of the dorsal surface of the hand. The 
persistence of anthrax infection in a room was well shown in the record of 
Keen's case. The infection lingered on the floor of the room in which the pa- 
tient had been operated upon for a long time. Three disinfections were neces- 
sary before it became impossible to obtain anthrax bacilli from the contami- 
nated floor. This indicates that such a case should be operated upon in a 
room not regularly used for operations. 

Hydrophobia, Rabies or Lyssa.— Hydrophobia is a spasmodic and 
paralytic disease due to infection through a wound with the virus from a rabid 
animal. The disease does not appear to arise except as the result of inocula- 
tion. It is most common in dogs and wolves, but it may develop in cats, 
horses, goats, foxes, cattle, sheep, and pigs. It is far more common in the 
carnivora than the herbivora. It is said that poultry may suffer from it. 
Human hydrophobia in most instances follows dog bites. Roux estimates 
that about 14 per cent, of the people bitten by mad animals develop the dis- 
ease. If the bite is on an exposed part, it is far more apt to cause rabies than 
if the rabid animal's teeth passed through clothing. The saliva is the usual 
vehicle of contagion, but other fluids and tissues contain the virus, especially 
the brain and cord. Hydrophobia has been known for centuries. It is 
not spoken of by Hippocrates, but is described by Aristotle, Pliny, and 
Celsus, and is alluded to by Plutarch. At the present day some ar- 
dent antivivisectionsts dispute its existence. The fact that an infant bit- 
ten by a rabid animal may develop rabies proves that the disease is not due 
to the imagination. Hydrophobia is almost invariably fatal. No causative 
bacterium has been demonstrated. One must exist but it probably escapes 
detection because of its very small size. The poison cannot gain entrance 
through sound mucous membrane. It used to be thought that the disease 
was particularly apt to arise in hot weather, but it is now known that it may 
occur any time of the year. No constant post-mortem lesions have been 
certainly demonstrated in those dead of rabies. Gowers believes that in the 
spinal cord there is hyperemia, but no infiltration with cells, whereas in the 
medulla, especially about the respiratory center, there are hypermia and cellu- 
lar infiltration of the perivascular spaces. But such perivascular infiltration 
can occur in some other acute conditions and hence is not characteristic. What 
is known as the rabic tubercle is found in the medulla and about the motor 
cells of the upper part of the spinal cord. Each tubercle consists of an aggre- 
gation of cells. Babes thinks the tubercle characteristic. Infiltration of the 
ganglia with epithelioid cells and round cells has been held by some to be 
characteristic. But both the rabic tubercle and ganglion infiltration occur 
in other conditions. The disease is extremely rare in the United States, 
and the author has never seen a single case. 

Symptoms. — The period of incubation of human hydrophobia is from a 
few weeks to several months, and it has been alleged that it may even be two- 



Symptoms of Hydrophobia 269 

years, but it is very doubtful if there is ever a period of incubation of over 
six or seven months. The average incubation period in man is forty days 
(Ravenel). The initial symptoms are mental depression, anxiety, sleepless- 
ness, restlessness, headache, malaise, and often pain or even congestion in 
the cicatrix. The anxiety which is usually present may be deepened into 
actual fear. In dogs the condition of fear is so evident that Cadius Aure- 
lianus centuries ago called the disease pantophobia (fear of evervthing). 
The previously-mentioned symptoms are quickly followed by dysphagia. 
It is not only water that is difficult to swallow but everything the patient 
tries to drink or eat. The difficulty in swallowing results apparently from 
apnea produced instantly when an attempt is made to swallow. Curtis 
points out that the difficulty is not spasm of the pharynx and larynx, but is 
a sense of immediate suffocation due to reflex stimulation of respiratorv 
inhibition. If spasms occur — and they may occur — they are secondary to 
this suffocative state, a state in which the action of the diaphragm ceases for 
a time. The air-passages become congested and the sufferer makes frequent 
and painful efforts to expel thick mucus, and the efforts produce paroxysms 
of suffocation. Between the paroxysms the patient is evidently somewhat 
breathless, and Warren tells us that his speech is not unlike that " of a child 
who has recently been crying and is endeavoring to control itself" ("Surgical 
Pathology and Therapeutics"). As the condition grows worse, suffocative 
attacks, which were at first induced by attempts at swallowing, come to be 
caused also by bright lights, sudden or loud noises, irritations of the skin, 
or even thinking of swallowing. At length suffocative paroxvsms occur 
spontaneously and the patient jumps, or hurls himself about, or the muscles 
of the entire body are thrown into clonic spasm. Tonic spasm does not occur. 
A condition of general hyperesthesia exists. The mind is usuallv clear, 
although during the periods of excitement there may be maniacal furor 
with hallucinations which pass away in the stage of relaxation. The tempera- 
ture is moderately elevated (101 to 103 F. or higher). The spasmodic stage 
lasts from one to three days, and the patient may die during this stage from 
exhaustion or from asphyxia. If he lives through this period, the convulsions 
gradually cease, the power of swallowing returns, and the patient succumbs 
to exhaustion in less than twenty-four hours, or he develops ascending par- 
alysis which soon causes cardiac and respiratory failure. In what is known 
as paralytic rabies, a very rare form of the disease in human beings, the 
attack comes on with the same early symptoms met with in the commoner 
form, but paralysis soon begins about the bitten part and spreads to all the 
limbs and to the trunk. 

In hydrophobia death is almost inevitable. Practically all cases in which 
it is alleged that recovery ensued were not true hydrophobia, but hvsteria. 
An exception must be made of Murri's case. Wood says that in hvs- 
teria, especially among boys, "beast-mimicry" is common, the suf- 
ferer snarling like a dog; and in the form known as "spurious hydropho- 
bia," in which there may or may not be convulsions, there are a dread of 
water, emotional excitement, snarling, and attempts to bite the bystanders 
(in genuine hydrophobia no attempts are made to bite, and no sounds are 
uttered like those made by a dog). 

Lyssa is separated from lockjaw by the paroxysms of suffocation and the 



270 Contusions and Wounds 

absence of tonic spasms in the former, as contrasted with the fixation of the 
jaws and the tonic spasms with clonic exacerbations of lockjaw. 

Treatment. — When a person is bitten by a supposed rabid animal and 
is seen soon after the injury, constriction should be applied if possible above 
the wound, the wounded area should be excised, cauterized with a hot iron 
or the Paquelin cautery, and dressed antiseptically. If the patient is not 
seen for a number of hours or a day or two after the injury, cauterization is 
useless; and it is not only useless, but it may delude the patient and his friends 
into a feeling of security. In any case, send the patient at once to a Pasteur 
institute. If the animal which inflicted the injury was not hydrophobic, no 
harm will result from inoculations; if it was hydrophobic, preventive treat- 
ment may save the patient. The method known as the preventive treatment 
was devised by Pasteur who discovered the following remarkable facts: If 
the virus of a rabid dog (street rabies) be placed beneath the dura of another 
dog, it always causes hydrophobia in from sixteen to twenty days, and inva- 
riably causes death. If the virus is passed through a series of rabbits it gets 
stronger (laboratory virus) , and if inserted beneath the dura of a dog it causes 
the disease in from five to six days, and kills in four or five days. The virus 
can be attenuated by passing it through a series of monkeys or by keeping 
it for a definite time. To obtain attenuated preparations in a convenient 
form Pasteur made emulsions from the spinal cords of hydrophobic rabbits, 
the animals having been dead two or three weeks. He found that the emul- 
sion obtained from the rabbit longest dead is the weakest. He injected a dog 
with emulsions of progressively increasing strength and made it immune to 
hydrophobia. The patient is injected with an emulsion made from the dried 
spinal cords of hydrophobic rabbits. In this emulsion the virus is attenuated,, 
and day by day the strength of the injected virus is increased. These emul- 
sions cause the body-cells to form antitoxin, and either the virus of street 
rabies does not develop at all or by the time it begins to develop a quantity of 
antitoxin is present to antagonize it. In the New York Pasteur Institute 
patients remain under treatment for fifteen days, two inoculations being given 
daily. In cases in which treatment is begun late, or in which the head or 
face was bitten, from four to six inoculations are given each day. The report 
of the Parisian Pasteur Institute shows that since its foundation there has 
been a mortality of 0.5 per cent. The lowest estimated number of those 
attacked by hydrophobia before this method was used was 5 per cent, of those 
bitten, and all attacked died; hence, the Pasteur treatment as applied in the 
Parisian Institute shows one-twenty-fifth of the mortality which attends other 
preventive methods. Ravenel, in 1901, estimated that 55,000 persons have 
been treated by the Pasteur method and that 1 per cent, have died. The 
value of this plan seems definitely established. The general public believe 
that the dog which did the biting should be killed. The dog should, if possi- 
ble, be locked up and watched rather than killed. It may be proved in this, 
way that it did not have hydrophobia. If it were necessary to kill the dog, 
or if the dog was killed at once or soon after, the physicians of the New York 
Pasteur Institute advise that the dog's head be cut from the body with an 
aseptic knife and a piece of the medulla oblongata be abstracted. The bit of 
medulla should be placed in a mixture of equal parts of glycerin and water 
which was previously sterilized by boiling. The bottle should be sealed and sent 



Glanders, Malleus, Farcy, or Equinia 271 

to the Institute, in order that inoculations may be made upon animals to 
prove the existence or absence of hydrophobia. In the paroxysm of hydro- 
phobia the treatment in the past was purely palliative. If we employ only 
palliative methods, keep the patient in a dark, quiet room, relieve thirst by 
enemata, saturate him with morphin, empty the bowels by enemata, attend 
to the bladder by regular catheterization, and during the paroxysms anes- 
thetize. Murri, of Bologna, cured a case of hydrophobia by injecting emul- 
sions of cords of rabbits dead six, five, four, and three days respectively. 
It would be proper to try this remedy if hydrophobia develops. A serum 
has been prepared by Tizzoni and Centani which they claim is successful 
in treating the disease as experimentally induced in the laboratory. The 
remarkable suggestion has come from Tizzoni, that rabies be treated with 
rays of radium, it having been shown that rabic virus can be destroyed by 
radium. 

Glanders, Malleus, Farcy, or Equinia.— Glanders is an infectious 
eruptive fever occurring in horses, asses, and some other animals, and communi- 
cable to man. If the nodules occur in the nares, the disease is called "glan- 
ders"; if beneath the skin, it is termed "farcy." This disease is due to the 
bacillus mallei and is communicated to man through an abraded surface or 
a mucous membrane. The characteristic lesions are infective granulomata 
in the nares, skin, lungs, and subcutaneous tissue. In the nares granulomata 
result in ulcers and under the skin break down into abscesses. From the 
site of inoculation the bacilli are disseminated and the cutaneous and muscular 
structures and lungs become involved. The disease is most common in the 
horse but occurs also in the ass, mule, cat, rabbit, goat, and other animals. 
Man can be infected from a diseased animal and as the common source of 
infection is the horse the usual victims are those who use or work about horses. 
The period of incubation after infection is four or five days. 

Acute and Chronic Glanders. — In acute glanders there is septic inflam- 
mation at the point of inoculation; nodules may form in the nose and ulcerate; 
there is profuse nasal discharge; the glands of the neck enlarge; there is 
weakness, frontal headache, chilliness, pain in the back and limbs; often diar- 
rhea; after a time the muscles become painful; there is fever, the evening tem- 
perature being ioo° or higher, and the morning temperature being lower. 
Chills may occur. There may be chest pains, severe muscular pain, bron- 
chitis, and signs of pulmonary congestion. It may not be suspected that 
the patient has glanders and the diagnosis of typhoid may perhaps be 
made. Twelve to fourteen days after the beginning of the trouble little 
hard lumps arise in the muscles and just beneath the skin. In a few davs 
the lumps soften, break down, and discharge a bloody fluid which contains 
the bacilli of glanders. In a number of cases an eruption resembling small- 
pox appears on the face and about the joints. It differs from smallpox in 
not being umbilicated. Leukocytosis exists. Mallein, a material correspond- 
ing to tuberculin, has been used for diagnostic purposes upon animals. 
Acute glanders is nearly always fatal. Chronic glanders lasts for months, 
is rarely diagnosticated, being mistaken for catarrh, and is often recovered 
from. The diagnosis can be made by injecting a guinea-pig with the 
nasal mucus. 

Acute and Chronic Farcy. — Acute farcy arises at the site of a skin- 



272 Contusions and Wounds 

inoculation; it begins as an intense inflammation, from which emerge inflamed 
lymphatics that present nodules or "farcy-buds." Abscesses form. There 
are joint-pains and the constitutional symptoms of sepsis, but no involvement 
of the nares. Chronic farcy may last for months. In it nodules occur upon 
the extremities, which nodules break down into abscesses and eventuate in 
ulcers resembling those of tuberculosis. 

Treatment. — In treating this disease the point of infection is at once to 
be incised and cauterized, dusted with iodoform, and dressed antiseptically. 
The skin over enlarged glands and swollen lymphatics is to be painted with 
iodin and smeared with ichthyol. Bandages are applied to edematous extrem- 
ities. Ulcers are curetted, touched with pure carbolic acid, dusted with iodo- 
form, and dressed antiseptically. In glanders the nostrils should be sprayed at 
frequent intervals with peroxid of hydrogen, and frequently syringed with a 
solution of sulphurous acid. The mouth must be rinsed repeatedly with 
solutions of chlorate of potassium. Abscesses are to be opened, mopped with 
pure carbolic acid, and dressed antiseptically. Stimulants and nourishing 
diet are imperatively demanded. Morphin is necessary for the muscular 
pain, restlessness, and insomnia. Digitalis is given to stimulate the circu- 
lation and kidney secretion. Sulphur iodid, arsenite of strychnin, and bichlo- 
rate of potassium have been used. Diseased horses ought at once to be killed 
and their stalls should be torn to pieces, purified, and entirely rebuilt. A 
man with chronic glanders should be removed to the seaside. The nasal 
passages must be kept clean and the ulcers must be cauterized and dressed 
with iodoform gauze. Nutritious foods, tonics, and stimulants are necessary. 

Actinomycosis is a specific infectious disorder characterized by chronic 
inflammation, and is due to the presence in the tissues of the actinomyces or 
ray-fungi. As stated on page 18 the ray-fungus occupies a position between 
bacteria and moulds and more than one variety of the fungus exists. Some 
of the varieties are pathogenic, others do not seem to be. It is anaerobic 
but when dried is not at once killed, but months after mav develop if placed 
under favorable conditions. When growing in the tissues it usuallv forms 
numerous distinct aggregations each about the size of a sand grain and called 
from their color sulphur grains. Usually the growths lie in purulent matter. 
If purulent matter containing growths is rubbed between the fingers it will 
give a gritty sensation like sand, if the growth is not very recent. The growth 
of the fungi causes the formation of an infective granuloma and great masses 
of granulation tissue may form with collections of necrotic or purulent matter 
here and there, and zones of fibrous tissue. The fungi are easily discovered 
in the sulphur grains with the microscope. This disease occurs in cattle 
{lumpy jaw) and in pigs, and can be transmitted to man, usually by the food. 
At the point of inoculation (which is generally about the mouth) arises an 
infective granuloma, around which inflammation of connective tissue occurs, 
suppuration eventually taking place. Inoculation in the mouth is by way 
of an abrasion of mucous membrane or through a carious tooth. Chewing 
straw which contains the fungi is the most common method of infection. 
The ray-fungi may pass into the lungs, causing pulmonary actinomycosis; 
into the intestines, causing intestinal actinomycosis; into the skin, the bones, 
the subcutaneous tissues, the heart, the brain, the liver, the urinary organs, 
etc. Abdominal anthrax is the commonest form and comprises nearly 50 



Actinomycosis 273 

per cent, of cases. Cases of human actinomycosis until very recently were 
looked upon as sarcomata. Many sinuses form, but large abscesses do not 
arise. 

The pus of actinomycosis contains many sulphur-yellow bodies visible 
to the naked eye and composed of fungi. These bodies usually feel gritty when 
rubbed between the fingers because of the presence of lime salts. 

In actinomycosis the adjacent lymph-glands are very seldom involved, and 
if metastasis occurs it takes place by the veins. The condition causes but 
slight pain. A diagnosis must be made from syphilis, sarcoma, and tubercu- 
losis. The formation of a tumor, followed by sinuses and ulceration, the 
ulcer having undermined edges and edematous granulation, and adjacent 
pus cavities joining by sinuses, the appearance of the pus, and the micro- 
scopic study of the discharge are significant. It is well to remember that an 
individual with actinomycosis may react to tuberculin like a person with 
tuberculosis. Actinomycosis may last for years, or it may prove fatal. 

Cutaneous actinomycosis may be secondary to visceral infection with the 
disease, may be a purely local condition, or may be associated with some 
adjacent area of bone-infection. The gummatous form of actinomycosis 
resembles a gummatous syphilitic area, and in it many small purulent pockets 
open by fistulae (Monestie). 

In the anthracoid form there are no distinct purulent collections, but many 
fistula? discharge pus at various points (Monestie). 

An area of cutaneous actinomycosis is characterized by the existence of 
violet, blue, gray, or black maculae, varying in size from that of a pin's head 
to that of a bean, the center of each macule being white and containing a 
minute quantity of pus (Derville). 

In actinomycosis of bone the bone enlarges and becomes painful, the parts 
adjacent swell from infiltration and soften, pus forms and reaches the surface 
through fistula*, and the skin becomes involved secondarily. 

Abdominal actinomycosis takes origin from the gastro-intestinal tract, 
an actinomycotic nodule of the intestine having ulcerated, adhesions having 
formed, and an actinomycotic abscess having arisen, or actinomycotic disease 
of the intestine having spread. In over fifty per cent, of cases of abdominal 
actinomycosis the cecum is the part attacked. A fecel fistula may form and 
the liver may be involved. The mortality of actinomycosis depends upon the 
site of infection, the question of secondary infection, and the plan of treatment. 
If pyogenic infection occurs fatal pyemia may arise. The prognosis is reason- 
ably good in many cases. The majority of cutaneous cases (nearly 90 per 
cent.) and many osseous cases can be cured. The mortality in the abdomi- 
nal cases is large. Grill says that of 77 abdominal cases treated surgically 45 
died, 22 recovered, and 10 were improved. Frazier (" Keen's System of 
Surgery") tells us that the mortality of the reported cases of actinomycosis in 
the United States was 47 per cent, and quotes Jiron as follows regarding the 
mortality of the various forms: Face and neck, 11 per cent.; thorax, 83 per 
cent.; abdomen, 71 per cent.; brain, 100 per cent. Actinomycosis has a 
strong tendency to redevelop even after apparently thorough excision. A 
case of cutaneous actinomycosis of the arm, seen by the author, was operated 
on twenty times. Ulceration took place into the axillary artery and death was 
narrow lv averted. Recoverv finally ensued. I have seen three cases of human 



274 Syphilis 

actinomycosis; one was the patient just referred to; another was a mattress 
stuff er (straw being used), his lesion was on the chest and jaw and recovery 
followed operation; the third was a stable hand, who died from a lesion of 
the face, jaw, and neck. 

Treatment. — Free excision if possible; otherwise incision, scraping, cau- 
terization with pure carbolic acid or silver nitrate, and packing with iodoform 
gauze. If possible remove the entire area, if not possible remove all we can. 
Sinus must be widely opened, each collection of pus must be drained, and 
granulation tissue if not extirpated must be scraped away with a sharp spoon. 
Give internally large doses of iodid of potassium. This drug alone has cured 
many cases. It is given for a week or two and is then discontinued for one 
week. Cases of actinomycosis should be placed under the best hygienic con- 
ditions, should live, as far as possible, in the sunlight and open air, and 
should be given nutritious diets, tonics, and often stimulants. 



XVI. SYPHILIS. 

Definition. — Syphilis is a chronic contagious, and sometimes heredi- 
tary, constitutional disease. It was long believed that only members of the 
human familv could take syphilis, but Metschnikoff and Roux have succeeded 
in inoculating chimpanzees ("Annals of Pasteur Institute," Dec, 1903). 
Its first lesion is an infecting area or chancre, which is followed by lym- 
phatic enlargements, eruptions upon the skin and mucous membranes, affec- 
tions of the appendages of the skin (hair and nails), "chronic inflammation 
and infiltration of the cellulovascular tissue, bones, and periosteum" (White), 
and, later, often by gummata. This disease is probably due to a microbe, 
but Lustgarten's bacillus has not been proved to be the cause. One fact 
against its being the cause is its presence in the non-contagious late gummata. 
The spirochaeta pallida occurs in the contagious lesions and there is consider- 
able evidence that it is the real cause (page 48). White quotes Fenger in his 
assumption that syphilitic fever is due to absorption of toxins; that the eruptions 
of skin and mucous membranes in the secondary stage arise from local deposit 
and multiplication of the virus; that many secondary symptoms result from 
nutritive derangement caused by tissue-products passing into the circulation;, 
that the virus exists in the body after the cessation of secondary symptoms; 
and that it may die out or may awaken into activity, producing "reminders." 

During the primary and secondary stages fresh poison cannot infect, and 
this is true for a long time after the disappearance of secondary symptoms. 
Immunity in the primary stage is due to products absorbed from the infected 
area. Colles's immunity is that acquired by mothers who have borne syph- 
ilitic children, but who themselves show no sign of the disease. Profeta's 
immunity is the immunity against infection possessed by many healthy children 
born of syphilitic parents. Tertiary syphilitic lesions are not due to the poison 
of syphilis, but to tissue-products resulting from the action of that poison, 
or to nutritive failure as a consequence of the disease. Tertiary syphilis is 
not transmissible, but it secures immunity. 

Transmission of Syphilis.— This disease can be transmitted— (1) by 
contact with the tissue-elements or virus — acquired syphilis; and (2) by 



Syphilitic Periods 275 

hereditary transmission — hereditary syphilis. The poison cannot enter 
through an intact epidermis or epithelial layer, and abrasion or solution of 
continuity is requisite for infection. Syphilis is usually, but not always, a 
venereal disease. It may be caught by infection of the genitals during coition, 
by infection of the tongue or lips in kissing, by smoking poisoned pipes, by 
drinking out of infected vessels, or by beastly practices. Syphilis not due to 
sexual relations is called syphilis oj the innocent. The barber is a danger, 
and cases are reported as following razor cuts and particularly the applica- 
tion of the alum stick to arrest bleeding. This stick is used over and over 
again and dried blood is often to be found upon it. I was consulted by a 
man who had been thus infected. I have treated two young girls infected 
by dentist's instruments, a policemen infected by a pipe, a glassblower infected 
from the blowpipe, and a street car driver who got the disease from a borrowed 
whistle. Bulkley ("Jour. Am. Med. Assoc," March 4, 1905) collected 1863 
cases following vaccination; 179 following circumcision; 82 following tattoo- 
ing, and 745 following cupping or venesection. The initial lesion of syph- 
ilis may be found on the finger, penis, eyelid, lip, tongue, cheek, palate, 
labium, vagina, anus, nipple, etc. Bulkley found that in 1810 cases the 
chancre was on the lip, in 1148 on the breast, in 734 in the mouth, in 432 
on the hand or one of the fingers, in 372 about the region of the eye, and in 
307 on the tonsil (F. D. Patterson, in "Therapeutic Gazette," Nov. 15, 1905). 
A person may be a host for syphilis, carry it, give it to another, and yet 
escape it himself (a surgeon may carry it under his nails, and a woman may 
have it lodged in her vagina). Syphilis can be transmitted by vaccination 
with human lymph which contains the pus of a syphilitic eruption or the 
blood of a syphilitic person. Vaccine lymph, even after passage through 
a person with pox, will not convey syphilis if it is free from blood and the 
pus of specific lesions; it is not the lymph that poisons, but some other sub- 
stance which the lymph may carry. 

Syphilitic Stages. — Syphilis was divided by Ricord into three stages: 
(1) the primary stage — chancre and indolent bubo; (2) the secondary stage 
— disease of the upper layer of the skin and mucous membranes; and (3) the 
tertiary stage — affections of connective tissues, bones, fibrous and serous 
membranes, and parenchymatous organs. This division, which is useful 
clinically, is still largely employed, but it is not so sharp and distinct as was 
believed by Ricord; it is only artificial. For instance, ozena may develop dur- 
ing a secondary eruption, and bone disease may appear early in the case. 

Syphilitic Periods.— White divides the pox into the following periods: 
(1) period of primary incubation— the time between exposure and the appear- 
ance of the chancre; from ten to ninety days, the average being twenty-five 
days; (2) period of primary symptoms — chancre and bubo of adjacent 
lymph-glands; (3) period of secondary incubation — the time between the ap- 
pearance of the chancre and the advent of secondary symptoms : about six 
weeks as a rule; (4) period of secondary symptoms — lasting from one to three 
years; (5) intermediate period — there may be no symptoms or there may be 
light symptoms which are less symmetrical and more general than those of 
the secondary period: it lasts from two to four years, and ends in recovery 
or tertiary syphilis; (6) period of tertiary symptoms — indefinite in duration. 
The fifth and sixth periods may never occur, the disease having been cured. 



276 Syphilis 

Primary Syphilis. — The primary stage comprises the chancre or infect- 
ing sore and bubo. A chancre or initial lesion is an infective granuloma 
resulting from the poison of syphilis and is most usually met with upon the 
genital organs. A chancre may be derived from the discharges of another 
chancre, from the secretion of mucous patches and moist papules, from syphi- 
litic blood, or from the pus or secretion of any secondary lesion. Tertiary 
lesions cannot cause chancre. It appears at the point of inoculation (page 275), 
and is the first lesion of the disease. During the three weeks or more requisite 
to develop a chancre the poison is continuously entering the system, and when 
the chancre develops the system already contains a large amount of poison. 
A chancre is not a local lesion from which syphilis springs, but is a local 
manifestation of an existing constitutional disease, hence excision is entirely 
useless. If we take the discharge of a chancre and insert it at some indifferent 
point, into the person from whom we took it, a new indurated chancre will 
not be formed, because the individual already has syphilis, but auto-inocu- 
lation with the discharge of an irritated chancre can cause a non-indurated 
sore. If we take the discharge of a chancre and insert it into a healthy per- 
son, an indurated chancre follows. Hence we say that primary syphilis is 
not auto-inoculable, but is hetero-inoculable. A soft sore can be produced 
in the lower animals by inoculation with the virus of a chancre, but a hard 
sore cannot except in chimpanzees. Some observers, notably Kaposi, of 
Vienna, advocate the unity theory. This theory maintains that both hard 
and soft sores are due to the same virus, the infective power of the soft 
chancre simply being less than that of the hard sore, the possibility of con- 
stitutional infection depending, not upon differences in the poison, but rather 
upon differences in the soil and in the local processes. The unicists advocate 
excision of chancres, soft or hard, to prevent, if possible, constitutional in- 
volvement. Most syphilographers believe in the duality theory, which we 
have previously set forth. This theory took origin from the classical investi- 
gations of Bassereau and Rollet. The duality theory maintains that the soft 
sore is caused by a poison different from that which originates the hard sore, 
and that a true soft sore never infects the system.* 

Initial Lesions. — An initial lesion, hard chancre, or infecting sore 
never appears until at least ten days after exposure; it may not appear for 
many weeks, but it usually arises in about twenty-five days. There are three 
chief forms of initial lesion: (1) a purple patch exposed by peeling epidermis, 
without induration and ulceration — a rare form; (2) an indurated area under 
the epidermis, without ulceration — a very common form; and (3) a round, 
indurated, cartilaginous area with an elevated edge, which ulcerates, exposing 
a velvety surface looking like raw ham; it bleeds easily, rarely suppurates, 
does not spread, and the discharge is thin and watery. This is the u Hunterian 
chancre," which is rarer than the second variety, but commoner than the first, 
and which ulcerates because of dirt, caustic applications, or friction. 

A chancre is rarely multiple; but if it is so, all the sores appear together as 
a result of the primary inoculation; they do not follow one another because of 
auto-infection. A hard sore does not suppurate unless irritated by caustics, 
friction, or dirt, or unless there be mixed infection with chancroid; its nature 

* For a full discussion of these points see the writings of Fournier, Alfred Cooper, 
and von Zeissl, and especially the great work of Taylor. 



Mixed Infection of Chancre and Chancroid 277 

is not to suppurate. The hardness may affect only the base and margins of 
an ulcer or it may affect considerable areas, but it has well-defined margins 
and feels like cartilage encapsuled, so that it can be picked up between the 
fingers. This hardness or sclerosis is due to gradual inflammatory exudation 
into "the tissue at the base of the ulcer and to growth of the nodule" (von 
Zeissl). It feels distinct from the surrounding tissues, like a foreign body 
lying in the part. A chancre untreated may last many months. The indu- 
ration usually disappears soon after the appearance of secondary symptoms. 
A copper-colored spot remains, and does not disappear until the disease is 
cured. Induration mav again appear before the outbreak of some distant 
lesion. 

Mixed Infection of Chancre and Chancroid.— Von Zeissl says: 
" If syphilitic contagion is mixed with pus, a chancre begins as a circumscribed 
area of hyperemia and swelling, which undergoes ulceration, and does not 
develop hardness for a period of from ten days to several weeks, and may 
develop a nodule after the first ulcer has entirely healed." This condition is 
seen when mixed infection occurs, the chancroid poison being quick, and the 
syphilitic poison being slow, to act. If chancroid poison is deposited some 
time after the syphilitic poison has been absorbed, the induration may appear 
in a few days after the chancroid begins. A soft chancre may appear upon an 
existing syphilitic nodule and may eat out the induration. 

Diagnosis of Chancre. — It is necessary to distinguish a chancre from a 
chancroid and from ulcerated herpes. A chancroid appears in from two to 
five days after contagion (always less than ten days) ; it may be multiple from 
the start, but, even if beginning as one sore, other sores appear by auto-inocu- 
lation; it begins as a pustule, which bursts and exposes an ulcer; the ulcer 
is circular, has thin, sharp-cut, or undermined edges, a sloughy, non-granu- 
lating base, and gives origin to a thin, purulent, offensive discharge which is 
both auto- and hetero-inoculable. These soft sores have no true sclerotic 
area, do not bleed, produce no constitutional symptoms, and are apt to be 
followed by acute inflammatory buboes which tend to suppurate. A chan- 
croid causes pain, and the original ulcer enlarges greatly. A chancre appears 
in about twenty-five days after inoculation (never before ten days) ; it is gen- 
erally single, but if multiple sores exist, they all appear together, for their dis- 
charge is not auto-inoculable if the sore is not irritated; an auto-inoculation 
of the products of an irritated chancre can at most produce only a soft purulent 
ulcer. A chancre begins as an excoriation or as a nodule; if an ulcer forms, 
its floor is covered with granulations and it is red and smooth; the discharge 
is thin and scanty and not offensive; the edges are thick and sloping; it is 
surrounded by an area of induration, and bleeds when touched, there appear 
about the same time with it indolent multiple enlargements of the adjacent 
glands, which rarely suppurate, and it is followed by secondary symptoms. 
A chancre causes little pain, and after it has existed for a few days rarely 
shows any tendency to spread. A urethral chancre appears after the usual 
period of incubation; it is situated near the meatus, one lip of which is usually 
indurated; the discharge is slight, often bloody, never purulent; indurated mul- 
tiple buboes arise; the sore can be seen, and constitutional symptoms follow. 

Herpetic ulceration has no period of incubation; it may follow fever, but 
usuallv arises from friction or irritation due to dirt or acrid discharges. It 



278 Syphilis 

appears as a group of vesicles, all of which may dry up, or some may dry up 
and others ulcerate, or they may run together and ulcerate. The edges of an 
herpetic ulcer are in "segments of small circles" (White); the ulcer is super- 
ficial, has but little discharge, and does not have much tendency to spread; 
it has no induration; it is painful; it is not accompanied by bubo unless sup- 
puration is extensive. Herpes is not followed by constitutional involvement. 

A chancre may be mistaken for cancer of the tongue. " A chancre of this 
region is brownish-red, a cancer being bright red. A chancre is soft in the 
center; a cancer presents uniformity of induration. A chancre gives origin 
to a thin, purulent discharge, free from blood; a cancer furnishes a non- 
purulent, bloody discharge. A chancre is soon followed by indolent lymphatic 
enlargements under the jaw; a cancer is followed by painful enlargements." 
A cancer is slower in evolution, is not followed by constitutional symptoms, 
and the lymphatic enlargements are much later in appearing than in chancre. 

Phagedena. — A chancre or a chancroid may be attacked by phagedena, a 
destructive form of ulceration which was once common, but at present is rare. 
The ulceration often spreads on all sides and also deeply into the tissues. In 
some cases it spreads at the edge in one direction (serpiginous ulceration), in 
some cases sloughing occurs. Phagedena occurs only in the debilitated (anemic, 
drunkards, strumous subjects, sufferers from diabetes, Bright's disease, etc.; 
salivation can cause it). The phagedenic ulcer is irregular, with congested 
and edematous edges, and a foul, sloughy floor. 

Chancre Redux. — Some observers believe that reinfection with syphilis 
is not very unusual (Hutchinson). Most authorities maintain that it is very 
rare (Taylor). The latter school maintains that the region once occupied by 
a chancre may, after many years, become indurated anew. Fournier pointed 
out this fact thirty years ago. Such a reinduration is called chancre redux, 
or relapsing chancre. 

If syphilitic manifestations follow such an induration, we must conclude 
that reinfection has truly occurred. If they do not follow, and this is the rule, 
the lesion is not really a chancre, but is probably a gumma in an early stage of 
development. Mauriac pointed out this last fact.* 

Syphilitic Bubo. — In syphilitic bubo anatomically related lymphatic 
glands enlarge about the same time as induration of the initial lesion begins. 
In the very beginning these glands may be a little painful, but the pain is 
slight and of temporary duration. These enlargements are called "indolent 
buboes"; they may be as small as peas or as large as walnuts, are freely mov- 
able, and very rarely suppurate. The lesion of the glands is hyperplasia of all 
the gland-elements and of their capsules, due to absorption of the virus. If 
the patient is tuberculous, the bubo is apt to become enormous, lobulated, and 
persistent. If the chancre appears on the penis, the superficial inguinal and 
femoral glands enlarge, usually on the same side of the body as the sore. If 
the sore is on the frenum, both groins are involved. If a chancre appears on 
the lip or tongue, the bubo is beneath the jaw. These buboes may remain 
for many months; they do not suppurate unless the sore suppurates or unless 
the patient is of the tuberculous type; and they finally disappear by absorption 
or fatty degeneration. About six weeks after buboes have formed in the 

* Mracek, in Wien. klin. Rundschau, 1896. H. G. Antony, in Chicago Medical Re- 
corder, April, 1899. 



Syphilitic Skin Diseases 279 

glands related to the lesion all the lymphatics of the body enlarge. General 
lymphatic involvement arises about the same time as the secondary eruption. 
The enlargement of the post-cervical and epitrochlear glands is diagnostically 
important. Glandular enlargements persist until after the eruptions have 
disappeared. 

Glandular enlargement always occurs in syphilis, but the bubo exists in 
only one-third of the chancroid cases. The bubo of syphilis is multiple, con- 
sisting of a chain of movable glands (the glanduke Pleiades of Ricord); the 
bubo of chancroid is one inflamed and immovable mass. The bubo of syph- 
ilis is indurated, painless, small, and slow in growth; the bubo of chancroid 
shows inflammatory hardness, is painful, large, and rapid in growth; the first 
rarely suppurates, the second often does. The skin over a syphilitic bubo is 
normal; that over a chancroidal bubo may become red and adherent. A syph- 
ilitic bubo is not cured by local treatment, but is cured by the internal use of 
mercury and is followed by secondary symptoms. A chancroidal bubo re- 
quires local treatment, is not cured by mercury, and is not followed by secon- 
daries. Herpes, balanitis, and gonorrhea rarely cause bubo, but when they do 
the bubo in each case is similar to that caused by chancroid. A positive 
diagnosis of syphilis can be made when an indurated sore on the penis is followed 
by multiple indolent buboes in the groin and by enlargement of distant glands. 

General Syphilis. — As the general lymphatic enlargement becomes 
manifest a group of symptoms known as "syphilitic fever" may appear. In 
many mild cases, however, fever is absent and the eruption is the first sign 
of constitutional involvement. The patient usually thinks he has a severe 
cold, is feverish and restless; complains of headache, lassitude, sleeplessness, 
and anorexia; his face is pale; he has intermitting rheumatoid pains in the 
joints and muscles, especially of the shoulders, arms, chest, and back, which 
pains change their location constantly and prevent sleep; night-sweats occur, 
and the pulse is quite frequent. The fever usually reaches its height in forty- 
eight hours, and falls as the eruption develops. The eruption develops 
usually in from forty-eight to seventy-two hours after the onset of the fever, 
but may not do so for one week or even more. The fever and the discomfort 
are worse at night. In type the fever may be intermittent, remittent, or con- 
tinued. Prolonged syphilitic fever with delay in the appearance of the erup- 
tion gives rise sometimes to great errors in diagnosis. In syphilitic fever there 
are anemia, trivial leukocytosis, and a marked fall in hemoglobin. Syphilitic 
fever may reappear during the progress of the disease. 

Secondary Syphilis. — The phenomena of secondary syphilis are due 
to poisoned blood. Fenger states that the poison is present in the blood 
during outbreaks, but not during the quiescent periods between outbreaks. 
Secondary syphilis is characterized by plastic inflammation, by the forma- 
tion of fibrous tissue, and by thickening of tissue. Superficial ulcerations 
may occur. Structural overgrowths appear (for instance, warts). 

Syphilitic Skin Diseases*— Syphilodermata (syphilides) are due to 
circumscribed inflammation, and may be dry or purulent. There is no one 
eruption characteristic of syphilis. This disease may counterfeit any skin 
disease, but it is an imitation which is not perfect and is never a counterpart. 
Syphilitic eruptions are often circumscribed; they terminate suddenly at their 
edges, and do not gradually shade into the sound skin. In color they are apt 



280 Syphilis 

to be brownish-red, like tarnished copper; especially is this the case in late 
syphilides. Hutchinson cautions us to remember that an ordinary non- 
specific eruption may be copper-colored, especially in people with dark com- 
plexions and when it occurs on the legs. Eruptions are apt to leave a brownish 
stain. Early syphilitic eruptions are symmetrical. Syphilitic eruptions have 
an affection for particular regions, such as the forehead, the abdomen and 
chest, the neck and scalp, about the lips and the alae of the nose, the navel, 
anus, groins, between the toes, and upon the palms and soles. Early secon- 
dary eruptions rarely appear on the face or hands. Specific eruptions are poly- 
morphous, various forms of eruption being often present at the same time, so 
that roseola is seen here, papules there, etc. These syphilides do not cause 
as much itching as do non-specific eruptions, except when they occur upon the 
scalp, about the anus, or between the toes. The late secondary eruptions 
tend to an arrangement in curved fines. 

Forms of Eruption. — The chief forms of eruption are: (i) erythema, 
(2) papular syphilides, (3) pustular syphilides, and (4) tubercular syphilides. 
Besides these eruptions pigmentation may occur (pigmentary syphilide), 
and blood may extra vasate (purpuric syphilide). 

Prince A. Morrow does not believe in erecting the vesicular syphilides into 
a special group. He tells us that vesicles sometimes form on erythemato- 
papular lesions, but their presence is an accident and not a regular phenom- 
enon. So, too, the bullous syphilide is a rare accident in a case, and even 
when it occurs soon becomes pustular. The pemphigoid syphilide is found 
almost exclusively in hereditary disease.* 

1. Erythema {macules, roseola, or spots). This eruption usually comes on 
gradually, crop after crop of spots appearing, and many days passing before 
an extensive area is covered. Occasionally, however, it arises suddenly 
(after a hot bath, after taking violent exercise, or after eating an indigestible 
meal). This eruption consists of circumscribed, irregularly round, hyperemic 
spots, about one-eighth of an inch in diameter, whose color does not entirely 
disappear on pressure in an old eruption but does in a recent one. The color 
is at first light pink, but it becomes red, purple, or even brown. In the papular 
form of erythema the spots are slightly elevated. Erythema is rare upon 
the face and the dorsum of the hands and feet. It attacks especially the chest 
and belly, but appears often on the forehead, the bend of the elbow, and the 
inner portion of the thigh, the neck, and the flexor surface of the forearms 
and arms. It appears first on the abdomen and last on the legs. Usually 
erythema follows syphilitic fever, about six weeks after the chancre appears, 
and the number and distinctness of the spots are in proportion to the violence 
of the fever. No fever or slight fever means there will be but few spots and 
they will soon disappear. In rare cases the eruption is very transitory, lasting 
but a few hours, but it usually continues for several weeks if untreated. It 
may pass away or may be converted into a papular eruption. Mercury will 
cause it to disappear in a couple of weeks. In examining for this form of 
eruption in a doubtful case, let cold air blow upon the chest and belly (Hearn) ; 
this blanches the sound skin and makes clear any discoloration. No desqua- 
mation attends the macular eruption, but a brownish stain remains for a vari- 
able time after the eruption fades. Erythema means, as a rule, a mild and 
* Morrow's "System of Genito-urinary Diseases, Syphilology, and Dermatology." 




Papular Syphilides 281 

curable attack. Macula' may be combined with the next form, constituting 
a maculopapular eruption. 

The maculopapular syphilides are evolved from the macular syphilides. 
They are slightly elevated, are situated upon hyperemic bases, and the sum- 
mits of some of them may undergo slight desquamation. A roseolar area 
may show one or several of these macular papules. They are apt to arrange 
themselves in segments of a circle, and are symmetrically distributed. This 
eruption usually appears early, but may appear late. It may fade and reap- 
pear several times in the same patient. The eruption lasts a few weeks. 

2. Papular syphilides, which w\ 

are papules or elevations covered 
with dry skin, may or may not des- 
quamate. If they do desqua- 
mate, the process begins over the 
center. They usually appear 
from the third to the sixth month 
of the disease. They may be pre- 
ceded by fever, and often reap- 
pear again and again. They are 
at first red, but become brownish. 
They are firm in feel and van- in 
size from the head of a pin to a 
five-cent piece or larger. They 
may be present as miliary pap- 
ules, lenticular papules, papules 
which scale off (papulosquamous 
eruption), and moist papules. 
Papules on fading leave coppery- 
looking stains. Papules upon 
the palms and soles constitute the 
so-called "palmar and plantar 
psoriasis," which appears from 
three months to one year after the 
appearance of the chancre. Pap- 



ules just below the line of the hair 
on the forehead constitute the Fig. 112.— Condylomata (Horwitz). 

corona veneris. Papular syph- 
ilides appear especially upon the forehead, the neck, the abdomen, 
and the extremities. The papular or squamous syphilide of the palms and 
soles begins as a red spot which becomes elevated and brownish; the epider- 
mis thickens and is cast off, and there then remains a central red spot sur- 
rounded by undermined skin. If papules are in regions where they are 
kept moist (as about the anus), they become covered with a sodden gray film 
which after a time is cast off and leaves the papule without epidermis. The 
sodden papules are called flat condylomata, moist or humid papules or plates 
(Fig. 112). Papules which are at first small may become large. The small 
or miliary papules constitute syphilitic lichen. The lenticular papules are 
most common, and strongly tend to scale off. The papular syphilides give a 
worse prognosis for the constitutional disease than do spots. 



282 Syphilis 

3. Pustular syphilides arise from papules. The condition is known 
as acne when the apex of the papule softens, impetigo when the whole papule 
suppurates, and ecthyma or rupia when the corium is also deeply involved. 
Vesicles occasionally precede pustules. The pustular eruption appears a 
number of months after infection and later than the papular. The pustular 
eruption gives a very bad prognosis for the constitutional disease. Rupia is 
formed by a pustule rupturing or a papule ulcerating, the secretion drying 
and forming a conical crust which continually increases in height and diam- 
eter, while the ulceration extends at the edges. When the crust is pulled off 
there is seen a foul ulcer with congested, jagged, and undermined edges. 
Rupia may be secondary or tertiary, and it invariably leaves scars. It appears 
only after at least six months have passed since the chancre began. Secondary 
rupia is symmetrical. Tertiary rupia is asymmetrical. 

4. Tubercular syphilides are greatly enlarged papules intermediate 
between ordinary papules and gummata. 

Diagnosis between Secondary and Tertiary Syphilides. — A secondary 
eruption is distinguished from a tertiary eruption by the following: the first 
tends to disappear, the second tends to persist and to spread; the first is gen- 
eral and symmetrical, the second is local and asymmetrical; the first does not 
spread at its edge, the second tends to spread at its edge, and this tendency, 
which is designated "serpiginous," produces an ulcer shaped like a horseshoe 
(Jonathan Hutchinson). Secondary lesions appear within certain limits of 
time, develop regularly, and are dispersed by mercurial treatment. Tertiary 
lesions appear at no fixed time, develop irregularly, and are not cleared up 
by mercury. 

Affections of the Mucous Membranes.— The chief lesions in syph- 
ilitic affections of the mucous membranes are mucous patches, warts, and 
condylomata. The first phenomena of secondary syphilis are, as a rule, 
symmetrical ulcers of the tonsils, painless, of temporary duration, and super- 
ficial (Hutchinson). The borders of the ulcers are gray, and the areas are 
reniform in shape. Catarrhal inflammations often occur. Eruptions appear 
on the mucous membranes as upon the skin. Mucous patches are papules 
deprived of epithelium; they are gray in color, are moist, and give off an offen- 
sive and virulent discharge. They usually appear as areas of congestion, swell- 
ing, and abrasion of the epidermis upon the lips, palate, gums, tongue, cheeks, 
vagina, labia, vulva, scrotum, anus, and under the prepuce. A moist papule 
of the skin is really a mucous patch. These patches, which are always circular 
or oval, are among the most constant lesions of the secondary stage, appearing 
from time to time during many months. If a patch has the papilla? destroyed, 
it is called a "bald patch.'''' If the papules present hypertrophied papillae 
fused together, there appear enlargements with flat tops, termed condylomata; 
if the papilla- of the papules hypertrophy and do not fuse, the growths are 
called warts (Fig. 134). Mucous lesions of the mouth are commonest in smok- 
ers and in those with bad or neglected teeth. Hutchinson says that persistence 
in smoking during syphilis may cause leukomata, or persistent white patches. 
The vagina and lips of the vulva during the secondary stage are often covered 
with mucous patches. The uterus may contain mucous lesions which poison 
the uterine discharge. The larynx may suffer from inflammation, eruptions, 
and ulceration (hence the hoarse voice which is so usual). The nasal mucous 



Affections of the Bones and Joints 283 

membrane may also suffer. The rectal mucous membrane may be attacked 
with patches, and so may the glans penis, the inner surface of the prepuce, 
and the urethra. Early in the secondary stage in some cases there is a slight 
muco-purulent urethral discharge, and examination with an endoscope shows 
redness of the mucous membrane of the anterior urethra. The discharge is 
contagious. The condition may be followed by constriction of the urethral 
caliber. Distinct ulceration may take place. 

Affections of the Hair. — In syphilis the hair is usually shed to a great 
extent. This loss may be widespread (beard, mustache, head, eyebrows, pubic 
hair, etc.) or it may be limited. Complete baldness sometimes ensues, but 
it is rarely permanent. The hairs of the head are first noticed to come out 
on the comb; on pulling them they are found loose in their sheaths — so 
loose that Ricord has said "a man would drown if a rescuer could pull only 
upon the hair of the head." The falling out of the hair, which is known as 
alopecia, usually begins soon after the fever or about the time of the erup- 
tion, but it may be postponed until much later. The skin of a syphilitic bald 
spot is never smooth, but is scaly. The hair may thin generally, baldness 
may appear in twisting lines, or it may be complete only in limited areas. Alo- 
pecia results from shrinking of the hair-pulp, death of the hair, and casting off 
of the sheath. 

Affections of the Nails. — Paronychia is inflammation and ulceration of 
the skin in contact with a nail and extending to the matrix. The nail is cast 
off partially or entirely. Onychia is inflammaion of the matrix, and is mani- 
fested by white spots, brittleness or extended opacity, twisting, and breaking 
off of the nail. The parts around are not affected. The damaged nail drops 
off and another diseased nail appears. 

Affections of the Ear. — Temporary impairment of hearing in one or 
both ears is not uncommon in syphilitic affections of the ear. Rarely, per- 
manent symmetrical deafness is produced. Meniere's disease is sometimes 
caused by syphilis. 

Affections of the Bones and Joints.— In syphilis there may be slight 
and temporary periostitis. Pain and tenderness arise in various bones, the 
pain being worse at night (osteocopic pains). Osteoperiostitis usually arises 
with or after the onset of the secondary eruption, but in rare instances pre- 
cedes the syphilides. The bones usually involved are the tibiae, clavicles, and 
skull. Intense headache may be due to periostitis of the inner surface of a 
cranial bone (Mauriac). Local periostitis may form a soft node which by 
ossification becomes a hard node. Pain like that of rheumatism may affect the 
joints. It is not increased by motion and is worse at night. Such pains 
are by no means uncommon and in some cases are very severe. The joints 
are not stiff except perhaps on rising. Paton reminds us that such arthralgia 
is an early symptom and may actually antedate the secondary eruption (" Brit. 
Med. Jour.," Nov. 28, 1903). More common than the above condition is 
synovitis, acute or chronic. It often comes on rapidly without other symptoms 
and is announced by swelling, tenderness, and pain. In some cases the pain 
is severe, and the patient is feverish or actually ill. Such cases constitute 
what is called syphilitic rheumatism, but the profuse sweats of acute rheu- 
matism are absent, the heart is never attacked, the skin is not red, the fever 
is not high, and the condition is not migrating (Paton, in "Brit. Med. Jour.," 



284 Syphilis 

Nov. 28, 1903). Hydrarthrosis may arise in the knee as a sequence of either 
of the above conditions, or, late in the secondary stage, it may arise without 
such an antecedent trouble (Paton). Symmetrical synovitis has been noted. 
Secondary syphilitic disease of bone, periosteum, and joints lasts only a short 
time and is never destructive. 

Affections of the Eye. — Iritis is the commonest eye trouble which may 
arise during secondary syphilis. It appears from three to six months after the 
chancre, and begins in one eye, the other eye soon becoming affected. The 
symptoms are a pink zone in the sclerotic, a congested, red or muddy iris, irreg- 
ularity of the pupil accentuated by atropin, the existence of pain and photo- 
phobia, and sometimes hazy or even clouded pupil. Rheumatic iritis causes 
much pain and photophobia, syphilitic iritis comparatively little; there is less 
swelling in the first than in the second; the former tends to recur, the latter 
does not. Iritis is usually recovered from, good vision being retained. Diffuse 
retinitis and disseminated choroiditis never occur until a number of months 
have passed since the infection. The symptoms are failure of sight, muscae 
volitantes, and very little photophobia. The diagnosis of retinitis and cho- 
roiditis is made by the ophthalmoscope. 

Affections of the Testes.— Syphilitic Sarcocele.— The testicle enlarges 
because of plastic inflammation. Both glands usually suffer, but not always. 
Fluid distends the tunica vaginalis. The epididymis escapes. The testicle 
is not the seat of pain, is troublesome because of its weight, and has very 
little of the proper sensation on squeezing. The plastic exudate is generally 
largely absorbed, but it may organize into fibrous tissue, the organ passing 
into atrophic cirrhosis. 

Intermediate Period. — Secondary lesions cease to appear in from 
eighteen months to three years. In the intermediate period no symptoms 
may appear, but the disease is still for some time latent and is not cured. 
Symptoms may arise from time to time. These symptoms, which are called 
"reminders," are not so severe as tertiary symptoms, are apt to be symmet- 
rical, and do not closely resemble secondary lesions. Among the reminders 
we may name palmar psoriasis and sarcocele. Sarcocele in this stage is 
bilateral and rarely painful. Bilateral indolent epididymitis occasionally 
occurs. Sores on the tongue, a papular skin-eruption, and choroiditis may 
arise. Gummata occasionally occur in this stage, but they are apt to be 
symmetrical and non-persistent. Arteritis may occur, beginning in the intima 
or adventitia, and causing, it may be, aneurysm, thrombosis, or embolism. 
Obliterative endarteritis may cause gangrene. Vascular changes are notably 
common in the vessels of the brain, and thrombosis may occur, in which case 
paralysis comes on gradually, preceded by numbness, although sudden 
paralysis may take place. These paralyses may be limited, extensive, transi- 
tory, or permanent. The nervous system often suffers in this stage (anesthetic 
areas and retinitis). The viscera are often congested and infiltrated (tonsils, 
liver, spleen, kidneys, and lungs). 

Tertiary Syphilis. — This stage is not often reached, the disease being 
cured before it has been attained. It is not so much a stage of syphilis as a con- 
dition of impaired nutrition which results from the disease. This view finds 
confirmation in the fact that tertiary lesions do not furnish the contagion. 
The primary stage disappears without treatment, the secondary stage tends 



The Gumma 285 

ultimately to spontaneous disappearance, but tertiary lesions tend to persist 
and to recur. Tertiary lesions may be single or may be widely scattered; 
when multiple they are not symmetrical except by accident. These lesions 
may attack any tissue, even after many years of apparent cure; they all tend 
to spread locally, they all leave permanent atrophy or thickening, they all tend 
to relapse, and a local intluence is often an exciting cause. 

Tertiary skin-eruptions are liable to ulcerate. Various eruptions may 
occur: papular syphilides, pustular syphilides, gummatous syphilides, ser- 
piginous syphilides, and pigmentary syphilides. The characteristic syphilide 
is rupia, which is formed by a pustule rupturing or a papule ulcerating. A 
brown or black crust forms because of the drying of the discharge, ulceration 
continues under the crust, new crusts form, and, as the ulcer is constantly 
increasing peripherally, the new crusts are larger in diameter than the old 
.ones and the mass assumes the form of a cone. An ulcer which has destroyed 




Fig. 113. — Gumma of the clavicle. 

the deeper layers of the skin is exposed by tearing off the crust. On healing 
a rupial ulcer always leaves a permanent scar. 

Serpiginous ulcers are common in tertiary syphilis, and are especially 
common about the knees, nostrils, forehead, and lips. Serpiginous ulceration 
is spoken of as syphilitic lupus. It is preceded by a widespread brown- 
colored nodular cutaneous infiltration. The nodules suppurate, run together, 
crust, and produce an ulcer which spreads rapidly and assumes the shape of 
a horseshoe. 

The Gumma.— The gumma is the typical tertiary lesion. In some cases 
there is a solitary gumma; in others, two or three or even many gummata. 
A gumma is a mass of granulation tissue, grayish-yellow in color, containing 
many cells and few fibers. Organization of the gumma fails to take place 
because of a want of sufficient blood-supply, the cellular mass is apt to undergo 
caseation, and when this occurs an ulcer forms. One portion of the mass 
may caseate, another portion may become fibrous. In some cases the entire 
gumma becomes fibrous. A gumma varies in diameter from one-eighth 
of an inch to two or three inches, presents a center of gummy degenera- 
tion, a surrounding area of immature fibrous tissue, and an outer zone of 
embryonic tissue and leukocytes. A gumma, when it is spontaneously evac- 
uated, exhibits a small opening or many openings with very thin red and 



286 Syphilis 

undermined edges; the ulcer is slow to heal, and forms a thin scar, white in 
the center, but pigmented at the margins and usually depressed (Jonathan 
Hutchinson, Jr.). The gummatous ulcer is deep, circular in outline, with 
undermined edges and an uneven floor covered with a thick, white, adherent 
slough. Sometimes there is no slough, but an extensive area is infiltrated. 
A gummatous ulcer may coalesce with one or more adjacent ulcers. The 
discharge is scanty and tenacious. These ulcers are often seen upon the 
legs, and when once healed rarely recur. A gumma in the internal organs 
may become a fibrous mass. Gummata form in the skin, subcutaneous 
tissues, muscles, tongue, joints, bursa?, testes, spinal cord, brain, and internal 
organs. In tertiary syphilis an inflammation may not form a circumscribed 
gumma, but, instead, may produce a diffuse degenerating mass. This type 
of inflammation, which is seen in bones, is called "gummatous." A healing 
gumma in a mucous canal such as the rectum or larynx causes thickening 
and stricture. Tertiary syphilis is a common cause of amyloid degeneration 
and the most frequent cause of arterial and nervous sclerosis. 

Various Lesions. — Hutchinson enumerates the lesions of tertiary syphilis 
as follows: Periostitis, forming nodes or causing sclerotic hypertrophy, or 
suppuration, or necrosis; gummata in various parts; disease of the skin of the 
type of rupia or lupus; gumma or inflammation of the tongue, causing scle- 
rosis; structural changes in the nervous system, causing ataxia, ophthalmo- 
plegia externa and interna, general paresis, optic atrophy, and paralyses of 
cerebral nerves; amyloid degenerations; and chronic inflammation of certain 
mucous membranes (of the mouth, pharynx, vagina, rectum, etc.), with thick- 
ening and ulceration. Gummatous osteoperiostitis of the vertebrae may 
arise, and this may be associated with disease of the membranes or cord. 
Syphilitic inflammation of vertebrae is called syphilitic spondylitis. Unilateral 
enlargement of the epididymis is sometimes noted, the mass feeling heavy, 
aching a little, but not being very tender. Unilateral sarcocele may be met. 

Tertiary Syphilis of Bones. — The bones particularly liable to disease 
are the skull, sternum, nasal septum, and tibia. The usual form is a gumma, 
resulting in caries and necrosis. A superficial gumma causes syphilitic peri- 
ostitis, a deep gumma, syphilitic osteomyelitis (McFarland's "Text-Book 
of Pathology"). Periostitis affects particularly the superficial bones (tibia, 
clavicle, sternum, ulna, etc.). It begins in the deeper layer of the periosteum, 
swelling arises, gummy changes occur, and the bone beneath is more or less 
destroyed. In the skull the bone may be completely penetrated. Not un- 
usually syphilitic periostitis arises at the seat of a trivial injury. Syphilitic 
osteomyelitis occurs particularly in the phalanges and skull. An area of 
syphilitic bone disease may undergo repair, osteosclerosis usually and osteo- 
porosis sometimes resulting (McFarland). 

Tertiary Syphilis of Joints. — (See the careful study of E. Percy Paton, 
in "Brit. Med. Jour.," Nov. 28, 1903). The knee-joint is most commonly 
affected. Chronic synovitis may arise with considerable or even great swell- 
ing (hydrarthrosis), trivial pain, slight functional impairment, some thicken- 
ing of synovial membrane, and some harshness or grating on movement 
(Paton). Gummatous synovitis may arise, a condition which sometimes 
follows the ordinary synovitis but more often exhibits very little swelling. The 
synovial membrane exhibits irregular areas of thickening and the symptoms 
resemble those of a tuberculous joint (Paton). 



Nervous Syphilis 287 

In some syphilitic joints the disease begins in the bone and cartilage. 
In such a condition there is rigidity, marked limitation of movement, pains 
not often severe, and some deformity (Paton). Again, as Paton points out, a 
joint may be involved by an adjacent syphilitic area, synovitis arising, or, if 
a gumma breaks into a joint, secondary pyogenic infection may follow. 
Ankylosis may follow joint syphilis. 

Visceral Syphilis. — Amyloid changes may occur in any of the viscera of 
an individual with tertiary syphilis, and such changes may be found in people 
in whom suppuration never occurred. The lungs may undergo fibroid 
induration (syphilitic phthisis). Syphilitic phthisis is a non-febrile malady. 
Gummata may form in the heart, liver, spleen, or kidneys. The capsule and 
fibrous septa of the liver may thicken, the organ being puckered by contrac- 
tion. Albuminuria may occur in tertiary syphilis. It may be caused by 
fibroid changes in the kidneys, by the formation of gummata, or by amyloid 
degeneration. Its occurrence should be watched for. Mercury and iodid 
of potassium have been regarded as causative of albuminuria in some cases. 

Syphilis may cause disease of the stomach, and probably does so more 
frequently than was formerly supposed, because it is difficult to distinguish 
from more common diseases. The condition may be gummatous infiltration 
of the walls of the stomach, multiple and minute gummata, ulcerations result- 
ing from breaking down of gummata, or syphilitic endarteritis of the gas- 
tric vessels. When ulcers heal cicatricial contraction results. Syphilitic 
ulcers and gummata of the stomach may be cured by efficient antisyphilitic 
treatment. Like lesions may form in the intestines. Flexner, Mracek, 
Frankel, Fournier, and others have discussed this subject.* 

Nervous syphilis may be manifested by disorders of the brain, cord, or 
nerves. It is rare after severe secondaries, and is most common when sec- 
ondaries were light or so trivial as to have escaped observation. Severe 
secondaries seem to cast off, mitigate, or exhaust the poison. Nervous syph- 
ilis may result directly from the specific disease, and such lesions are truly 
syphilitic. It may result indirectly from the specific disease, and such lesions 
are called parasyphilitic. For instance, a gumma of the brain is a true syph- 
ilitic lesion, but locomotor ataxia following syphilis is a parasyphilitic lesion. 
Syphilitic lesions are improved or cured by antisyphilitic treatment, para- 
syphilitic conditions are not. Brain syphilis is usually a late phenomenon 
(from one to thirty years after infection). The lesion may be gumma of the 
membranes (tumor), gummatous meningitis, arterial atheroma, or obliterative 
endarteritis. A gumma may eventuate in a scar, a cyst, or a calcareous mass. 
The symptoms of brain syphilis depend on the nature, seat, and rate of devel- 
opment of the lesions. It is to be noted that syphilitic palsy is apt to be limited, 
progressive, and incomplete. Epilepsy appearing after the thirtieth year is 
very probably specific if alcohol as a cause can be ruled out. Persistent head- 
ache, tremor, insomnia or somnolence, transitory, limited, and erratic palsies, 
unnatural slowness of utterance, amnesia, vertigo, and epilepsy are very 
suggestive of syphilis. Sudden ptosis is very significant; so is sudden palsy 
of one or more of the extrinsic eye-muscles. In syphilitic insomnia the patient 
cannot get to sleep at night for a long while, but when he once gets to sleep he 
reposes well. The type of insanity which is most apt to arise is a likeness or 
counterpart of general paralysis, and, like ordinary paresis, it is not curable- 
* See editorial in Jour. Amer. Med. Assoc, March 24, 1900. 



288 Syphilis 

Spinal syphilis may cause sclerosis, a condition like Landry's paralysis, 
softening, and tumor. Neuritis is not uncommon in syphilis. Many of the 
diseases which follow syphilis are due to it only indirectly, and are not bene- 
fited by specific treatment. Among them are paresis and locomotor ataxia. 

Justus's Test for Syphilis.— The test consists in first estimating the 
amount of hemoglobin present, then making a single mercurial inunction, 
and again estimating the hemoglobin. It is claimed that the corpuscles of 
an untreated syphilitic are unduly sensitive, and if the disease is present a 
mercurial inunction will cause a loss of 10 to 20 per cent, of hemoglobin 
within twenty-four hours, which fall persists a few hours and is then followed 
by a rise to a level above that which existed when the test was applied. It is 
often demonstrable in secondary, tertiary, or congenital syphilis. It usually 
fails in latent cases and in early secondary syphilis, and in some diseases 
other than syphilis the reaction can be obtained. I regard the test as unreliable. 

Treatment of the Primary Stage.— A chancre should not be excised. 
The disease is constitutional when the chancre appears, and excision and 
cauterization inflict needless pain and do no good. The initial lesion should 
never be cauterized unless it is phagedenic or becoming so. Order the patient 
to soak the penis for five minutes twice daily in warm salt water (a teaspoonful 
of salt to a cupful of water) , and then to spray the sore with peroxid of hydro- 
gen diluted with an equal bulk of water. The ulcer is then dried with absor- 
bent cotton and on it is dusted a powder composed of equal parts of bis- 
muth and calomel. The buboes in the groin require no local treatment 
unless they tend to suppurate. If they persist or become large, paint them 
with iodin or rub ichthyol ointment or mercurial ointment into them, and 
apply a spica bandage to the groin. Some authorities give mercury in this 
stage in order to prevent secondaries. The younger Gross opposed this 
strongly, and affirmed a wish to see the secondary eruption — first, because 
it proves the diagnosis; and, second, because it affords valuable prognostic 
indications (an erythematous eruption means a light case, an early pustular 
eruption means a grave case with serious complications); I have always 
followed the plan of Gross, and do not order mercury until constitutional 
symptoms develop. If phagedena arises, place the patient at once upon 
stimulants and nutritious diet, secure sleep, and destroy the ulcer by the use 
of nitric acid or the cautery while the patient is anesthetized. After cau- 
terization dust the sore with iodoform and dress with wet antiseptic gauze. 
Several times a day change the dressings, and at each change sprav the sore 
with peroxid of hydrogen, irrigate with bichlorid of mercury solution, and 
dust with iodoform. It may be necessary to cauterize several times. In 
some cases it will be necessary to employ continuous irrigation with an anti- 
septic fluid. These cases are sometimes fatal and usually produce great 
destruction of tissue. In chancre redux watch carefully for the symptoms in 
order to determine if the condition is really one of reinfection or if we are 
dealing with a gumma which resembles a chancre in appearance. 

Treatment of the Secondary Stage.— The chance of cure in most cases 
is excellent if the patient follows advice. The prognosis is much worse if the 
patient is a hard drinker or is the victim of Bright's disease, diabetes, tuber- 
culosis, or other chronic exhausting malady. In the secondary stage the aim is 
to cure the disease. That it can be cured is known because reinfection occurs 
in some persons. The old axiom, "Syphilis once, syphilis ever, "is not true. 



Treatment of the Secondary Stage 289 

Diet and General Care. — In the beginning of treatment the patient must 
see his physician every day or two until the proper dose of mercury has been 
ascertained. For the following six months he should see his physician once 
a week, and during the next six months once every other week. During the 
second year he needs to see him once every month. Of course, if complica- 
tions arise at any period the visits must be more frequent. At the beginning 
of the attack he must have his teeth put in perfect order. Tobacco is abso- 
lutely forbidden because its use favors the development of mucous patches in 
the mouth. Alcohol as a beverage is prohibited. It is used only as a medi- 
cine. The teeth should be gently scrubbed with a soft brush in the morning, 
in the evening, and after each meal, and a mild astringent or antiseptic mouth- 
wash is to be used several times a day. The patient should wear flannel in 
winter. The author believes Guiteras's rules are sound, and in accordance 
with them directs the patient to refrain from kissing any one on the lips and 
from using a common towel, wash-rag, cup or glass, pipe or razor. He is told 
to sleep alone in bed, to wash his hands often, to wear gloves, and to keep his 
fingers out of his mouth. Every morning he should take a warm bath, being 
especially careful to cleanse the anus, perineum, axilla?, groins, and between 
the toes; and after the bath these parts should be dusted with borated talc 
powder. A Turkish bath once a week is ordered by Guiteras when no skin- 
eruption exists. The patient must avoid drafts, cold and wet ; must take a 
moderate amount of gentle outdoor exercise, and must sleep eight hours out of 
the twenty-four. The diet is of importance, and in this, too, the author fol- 
lows Guiteras and orders the patient to avoid eating anything fried, or any 
meat or fish which has been canned, salted, or preserved. Fruits, pickles, 
tea, condiments, alcoholic beverages, clams, pork, veal, and pastry are not to 
be taken. (See article by Luke Begg in "Phila. Med. Jour.," June 7, 
1001.) 

Medical Treatment. — Mercury must be used, the form being a matter 
of choice. Fournier advocated intermittent treatment. In this plan give 
gr. J of protiodid of mercury daily for six months, then stop for a month ; 
then give mercury for three months, then stop two months. During the first 
year the patient is under treatment nine months, and during the second year 
eight months. Some prefer the intermittent and others the continuous plan 
of treatment. The author prefers the continuous plan. In following the 
continuous plan find the patient's tolerance to mercury, and keep him for two 
years on daily doses below the amount he will tolerate. Gross's rule for con- 
tinuous treatment is to order pills of green iodid of mercury, each pill con- 
taining gr. i. The patient is ordered one pill after each meal to begin with; 
the next day the after-breakfast dose is increased to two pills; the following 
day the after-dinner dose is two pills, and so on, one pill being added 
every day. This advance is continued until there is slight diarrhea, griping, 
a metallic taste, or tenderness on snapping the teeth together, whereupon one 
pill is taken off each day until all unfavorable symptoms disappear. Then 
the dose is reduced one-half and this amount is called the tonic dose. This 
experimentation finds a dose on which the patient can be kept with entire 
safety for a long time; but if it is found that colic or diarrhea is apt to recur, 
there must be added to each pill gr. -^j of opium. The patient is given mer- 
cury in this way for two years. Every time new symptoms appear the dose 
19 



290 Syphilis 

is raised, and as soon as they disappear it is lowered to the standard. If the 
protiodid is not tolerated, give the bichlorid : 

U Hydrarg. chlor. corros. , gr. j; 

Syr. sarsaparillre comp., f 3 iij . — M. 

Sig. — f 3 , in water, after meals. 

Mercury with chalk in 1- or 2 -grain doses four times a day, with or without 
Dover's powder in i-grain doses, may be used. Mercurial inunctions pro- 
duce a rapid effect, but irritate the skin. The drug should be rubbed in with 
a gloved hand. There can be used once a day \ dram of oleate of mercury 
(10 per cent.) or 1 dram of mercurial ointment, rubbed into the skin. The 
first day it is rubbed into the inside of one thigh, the second day into the inside 
of the other thigh; the third day into the inside of one arm; the fourth day 
into the other arm; next, into one groin and then into the other groin, and then 
inunction is again made at the point of original application, and so on. After 
the rubbing the patient puts on underclothes and goes 'to bed, and in the 
morning takes a bath. The ointment may be smeared on a rag, which is then 
worn between the stocking and sole of the foot during the day. 

Fumigation is performed by volatilizing each night 3j of calomel. The 
patient sits naked on a cane-seat chair, and is wrapped up to the neck in a 
blanket which drops tent-like to the floor; the calomel is put upon an iron 
plate under the chair, and is heated by an alcohol lamp beneath the plate. 
The skin becomes coated with calomel, and the subject, after putting on woolen 
drawers and an undershirt, gets into bed. Hypodermatic injections of mer- 
cury are used by some physicians. They cause an eruption to disappear 
rapidly, but may produce abscesses, and relapses are prone to occur. I 
agree with Dr. Orville Horwitz that the hypodermatic method will not abort 
the disease; should never be a routine treatment; in suitable cases it is very 
valuable for symptomatic use, as when lesions on the face or in important 
structures make a rapid impression desirable or necessary; in cases which ob- 
stinately relapse under other treatment, and in syphilis of the nervous system. 
J. William White, after a large experience with this method, says that hypo- 
dermatic injections of corrosive sublimate are painful and are strongly objected 
to by many patients; that this method of treatment is occasionally dangerous 
and even fatal ; that it is liable to be followed by local complications (erythema, 
nodosities, cellulitis, abscess, sloughing) ; that it cannot be carried out by the 
patient, but requires the surgeon's constant intervention. This syphilographer 
concludes that hypodermatic medication does not offer advantages justifying 
its use as a systematic method of treatment, and that it encourages insufficient 
treatment — those "short heroic courses" which Hutchinson shows are fol- 
lowed by the gravest tertiary lesions. "The claim that by a few injections 
the time of treatment can be measured by months or even by weeks, instead 
of by years, would seem, as Mauriac has said, to involve the idea that mercury 
given hypodermatically acquires some new and powerful curative property 
which, given in other ways, it does not possess." * The usual plan is to give 
daily a hypodermatic injection of corrosive sublimate deep into the back or 
buttock, the dose being gr. \ of the drug. Thirty such injections are used 
unless some contraindication demands their discontinuance sooner. The 

* J. William White, in Morrow's "System of Genito-urinary Diseases, Syphilology, and 
Dermatology." 



Acute Ptyalism, or Salivation 291 

treatment is then stopped. If the symptoms recur, however, the patient is 
given another course, the daily dosage being gr. £, the treatment being again 
stopped after thirty injections, but being continued anew in |-grain doses if 
the svmptoms recur. The following preparation is used by some syphilo- 
graphers: 0.5 of a part of corrosive sublimate, 3 parts of guaiacol, and 97 parts 
of sterile olive oil. Thirty minims contains gr. -^ of corrosive sublimate. This 
mixture should be thrown deeply into the buttock and it causes no pain. The 
use of gray oil hypodermatically has warm advocates. It is claimed that it 
provokes but little pain and irritation, and that it is a very efficient remedy. 
The oil must be warmed and shaken before being used. Lang injects gr. J 
to gr. 1^ of the 50 per cent, gray oil, or twice this quantity of the 30 per cent. 
oil, twice during the first week, once during the second week, and after this 
once a week or once every other week for an indefinite period of time. It may 
be given oftener if symptoms arise or persist. 

Tavlor believes that gray oil may give rise to unpleasant and sometimes 
even to dangerous symptoms, and that it should be used with extreme care and 
onlv in selected cases in which other remedies are contraindicated. He says 
that in reading about the hypodermatic method he has been struck with the 
fact that "the most serious results have almost invariably followed injections 
in which fatty matters have been the vehicle of suspension." * 

Some surgeons employ intravenous injections of mercury. Lane injects, 
at first every other day and later daily, 20 ttl of a 1 per cent, solution of cyanid 
of mercury. The skin in front of the elbow is rendered aseptic, a fillet is tied 
around the arm, the needle is inserted into a vein, the fillet is loosened, the 
fluid is injected, and the needle is withdrawn. This method of using mercury 
is painless and produces a rapid effect. It may be used in nervous syphilis, 
but should not be used as a routine. In whatever way mercury is given, do 
not allow it to produce salivation (hydrargyrism or ptyalism). Always re- 
member that mercury may cause albuminuria and examine the urine at regular 
intervals during a course of the drug. If albumin appears in the urine, cut 
down the dose of mercury or stop the drug for a time. In the beginning of a 
case of syphilis, if the kidneys are found to be diseased, give the mercury 
cautiously, and never fail to examine the urine at regular intervals. An 
individual can take more mercury in summer than in winter because during 
the warm weather perspiration favors elimination. 

Throughout the mercurial course the patient should be weighed once a 
week, and if it is at any time found that the weight is decreasing, tonics, con- 
centrated food, and cod-liver oil are ordered. If the weight continues to 
grow less and the health begins obviously to fail, stop the mercury for a time, 
continue the cod-liver oil, tonics, and nourishing food, and order hot baths, 
fresh air, iron, and chlorid of gold and sodium. In order to cure syphilis 
mercury should be given for two years, and the mercurial course must be 
followed by at least a six months' course of iodid of potash. Reminders re- 
quire both iodid of potash and mercury (mixed treatment). 

Acute Ptyalism, or Salivation. — In acute ptyalism the saliva be- 
comes thick and excessive in amount; the gums become spongy and tender and 
liable to bleed. Tenderness is detected early by snapping the teeth. A 
metallic taste is complained of; the breath becomes fetid; the oral structures 

* "Venereal Diseases," by Robert W. Taylor. 



292 Syphilis 

swell; the teeth loosen; the saliva is produced in great quantity; and there are 
purging, colic, and exhaustion. Sometimes there are fever and a diffuse 
scarlatiniform eruption upon the skin. A chronic hydrargyrism may be 
shown by salivation, gastro-intestinal disorder, emaciation, mental depression, 
weakness, albuminuria, and tremor. To avoid salivation, advance the dose 
with great caution and instruct the patient as to the first signs of the trouble. 
He should use a soft toothbrush and an astringent mouth-wash (gr. xlviij of 
boric acid to siv each of Listerine and water). When ptyalism is noted, dis- 
continue the administration of the drug. Employ the above mouth-wash or 
one composed of a saturated solution of chlorate of potassium. Order gr. 
Y^-q- of atropin twice a day, and in bad cases spray the mouth with peroxid of 
hydrogen and use silver nitrate locally (gr. xx to 5j). Give stimulants (iron, 
quinin, and strychnin) and nutritious food. A weekly Turkish bath is of 
great service. In chronic hydrargyrism stop the administration of the drug, 
use tonics, stimulants, open-air exercise, Turkish baths, and nutritious food. 
The chlorid of gold and sodium forms a substitute for mercury. The use of 
iodid of potassium is of questionable value in ptyalism. 

Treatment of Complications in the Secondary Stage. — The compli- 
cations of the secondary stage usually require local applications in addition 
to general remedies. Mucous patches in the mouth should be touched with 
bluestone every day, an astringent mouth-wash being employed several times 
daily. If the patches ulcerate, they should be touched once a day with lunar 
caustic; if these areas proliferate, they should be excised and cauterized. 
Vegetations or growing papules on the skin must, if calomel powder fails to 
remove mem, be cut away with scissors and be cauterized with chromic acid 
or with the Paquelin cautery. Condylomata demand washing with ethereal 
soap several times daily, thorough drying, dusting with equal parts of calomel 
and subnitrate of bismuth or with borated talcum, and covering with dry 
bichlorid gauze. If these simple procedures fail, excise and cauterize. 

For psoriasis of the palms and soles diachylon ointment, mercurial plaster, 
or painting with tincture of iodin should be employed. Ulcers of paronychia 
are dressed with iodoform and corrosive sublimate gauze. Deep cutaneous 
ulcers are cleaned once a day with ethereal soap, sprayed with peroxid of 
hydrogen, dressed with iodoform and corrosive sublimate gauze and bandaged. 
When the process of granulation is well established dress with 1 part of un- 
guent, hydrarg. nitratis to 7 parts of cosmolin. In sarcocele mercurial oint- 
ment should be rubbed into the skin of the scrotum or the testicle be strapped. 
In alopecia the hair should be kept short, and every night the scalp should be 
cleaned with equal parts of green soap and alcohol rubbed into a lather with 
water. After the soap has been washed out some hair tonic should be rubbed 
into the scalp with a sponge. A favorite preparation of Erasmus Wilson's 
consisted of the following ingredients: 

K . Ol. amygd. dil., 

Liq. ammonise, ad f 3 j; 

Sp. rosemarini, 

Aquae mellis, aafgiij. — M. 

Ft. lotio. 

One part of tincture of cantharides to 8 parts of castor oil may be rubbed into 
the scalp. Solutions of quinin are esteemed by some. A useful wash for the 



Tertiary Stage 293 

scalp is the following: 3j of borate of sodium, 3j of spirits of camphor, 3ij 
of glycerin, and sufficient orange-flower water to make f3iv. 

In treating persistent skin-lesions, inunctions, injections, fumigations, or 
mercurial baths may be used. Baths are suited to patients with delicate skins, 
to those whose digestion fails when mercury is given by the mouth, and to 
those whose lungs will not tolerate fumigations. Half an ounce of corrosive 
sublimate with 4 scruples of sal ammoniac are mixed in about 4 ounces of 
water; this is added to a bath at a temperature of 95 F. The patient gets 
into this bath, covers the tub with a blanket, leaving only his head exposed, 
and remains in the bath an hour or so. Mercurial baths may rapidly cause 
salivation. 

Tertiary Stage. — If at any time during the case there appear tertiary 
symptoms, the patient should be put on mixed treatment. In any case, after 
two years of mercury add iodid of potassium to the treatment. White's rule 
is to use mixed treatment for at least six months (if any symptoms appear), 
the six months' course dating from their disappearance. This emphasizes 
the fact that the iodids alone will not cure tertiary syphilis. In obstinate 
tertiary lesions and in nervous syphilis the iodids should be run up to an 
enormous amount (from 30 to 250 grains per day). Sometimes people can 
take large doses of iodid when small doses produce iodism. Cyon explains 
this curious fact as follows: small doses combine with some products of the 
thyroid gland and form toxic iodo-thyrin. Large doses are diuretic, form 
soluble salts, and are rapidly eliminated. An easy way to give iodid is to order 
a saturated solution each drop of which equals about one grain of the drug. 
Each dose of the iodid is given one hour after meals and in at least half a glass 
of water. If the iodid disagrees, it may be given in water containing one dram 
of aromatic spirit of ammonia or in milk. The iodid of sodium may be 
tolerated better than the potassium salt, or the iodids of sodium, potassium, 
and ammonium may be combined. In giving the iodids begin with a small 
dose. During a course of the iodid always give tonics and insist on plenty of 
fresh air. Arsenic given daily tends to prevent skin-eruptions. The iodids 
when they disagree produce iodism — a condition which is made manifest by a 
flow of mucus from the nose, conjunctival irritation, a bad taste in the mouth, 
exhaustion, anorexia, nausea, and tremor. In some subjects there are out- 
breaks of acne, vesicular eruptions, or even bullae or hemorrhages. Iodism 
calls for the abandonment of the drug, and the administration of increasing 
doses of Fowler's solution, of arsenic, of laxatives, of diuretic waters, or, if 
there is great exhaustion, of stimulants. In some cases belladonna is of 
service. Some patients who cannot take the alkaline iodids may take syrup 
of hydriodic acid. After the patient has been for six months under mixed 
treatment without a symptom, stop all treatment and await developments. 
If during one year no symptoms recur, the patient is probably cured ; if symp- 
toms do recur, there must be six months more of treatment and another year of 
watching. 

The Question of Marriage. — Fournier has insisted that it is a great wrong 
to tell a syphilitic that he can never marry. He must not marry until he is 
cured, and he is not cured until, after the cessation of the use of iodid, he goes 
one year without treatment and without symptoms. 



294 Syphilis 

Hereditary Syphilis. — Transmitted congenital syphilis is heredi- 
tary syphilis manifest at birth. Acquired syphilis (except in the case of a 
woman who obtains the disease from a fetus) always presents the chancre as 
an initial lesion; hereditary syphilis never does. Hereditary syphilis may 
present itself at birth, and usually shows itself within, at most, the first six 
months of extra-uterine life. In rare cases (tardy hereditary syphilis) the 
disease does not become manifest until puberty. 

Rules oj Inheritance. — According to von Zeissl,* the rules of inheritance are 
as follows: 

i. If one parent is syphilitic at the time of procreation, the child may be 
syphilitic. 

2. Syphilitic parents may bring forth healthy children. 

3. If a mother, healthy at procreation, bears a child syphilitic from the 
father, the mother must have latent pox or must be immune, having become 
infected through the placental circulation. She often shows no symptoms, 
having received the poison gradually in the blood, and having thus received, 
it may be said, preventive inoculations. Certain it is that mothers are almost 
never infected by suckling their syphilitic children (Colles's law). 

4. If both parents were healthy at the time of procreation, and the mother 
afterward contracts syphilis, the child may become syphilitic, and the earlier 
in the pregnancy the mother is diseased, the more certain is the child to be 
tainted. This is known as ''infection in utcro." 

5. The more recent the parental syphilis, the more certain is infection of 
the offspring. The children are often stillborn. 

6. When the disease is latent in the parents it is apt to be tardy in the 
children. 

7. The longer the time which has passed since the disappearance of 
parental symptoms, the more improbable is infection of the children. 

8. In most instances parental syphilis grows weaker, and after the parents 
beget some tainted children they bring forth healthy ones. 

Syphilis in the mother is more dangerous to the offspring than syphilis in 
the father. The frequent immunity of the mother is due to the fact that her 
tissues produce antitoxins under the influence of the slowly absorbed virus. 

Many women affected with hereditary syphilis are sterile. Many syph- 
ilitic women abort before the eighth month, most commonly in the fifth 
month. The fetus very often dies at an early period of gestation. This may 
be due to a gummatous placenta or to a degeneration of placental follicles. 

Evidences oj Hereditary Syphilis (manifest at, or oftener soon after, birth). 
— Hutchinson says that at birth the skin is almost invariably clear. In from 
six to eight weeks " snuffles" begin, which are soon followed by a skin-eruption, 
by body-wasting, and by a chain of secondary symptoms (iritis, mucous 
patches, pains, condylomata, etc.). The child looks like a withered-up old 
man. Eruptions are met with on the palms and soles. Intertrigo is usual. 
Cracks occur at the angles of the mouth, and leave permanent radiating scars. 
The abdomen is tumid, and there is apt to be exhausting diarrhea. The 
secreting and absorbing glands of the intestinal tract atrophy. f It is doubtful 
if distinct gummatous tumors form in hereditary syphilis. The type of dis- 

* " Pathology and Treatment of Syphilis." 
f Coutts, in Brit. Med. Jour., 1894, No. 1643. 



Diagnosis of Hereditary Syphilis 295 

ease induced is a diffuse interstitial cellular change in the viscera, and the 
viscera are much more apt to suffer than in acquired syphilis. The liver, 
spleen, and pancreas often enlarge from interstitial changes, and the lungs 
sometimes are attacked in the same manner. Sometimes synovitis or arthritis 
arises, the condition being similar to that met with in acquired syphilis. 
A form encountered between the third month and end of the second year, 
according to Paton, is characterized by growth into the joint of fungating 
granulation tissue, the joint is useless, and the parts about are swollen and 
edematous. Atrophic lesions may appear in the bones. In the skull the bone 
may be softened by removal of its salts or be thinned by the pressure of the 
brain. In the long bones the epiphyseal lines suffer, the attachment of the 
epiphyses to the shafts is weak, and separation is easily induced. Epiphy- 
sitis is common, rarely causes pain, and rarely leads to suppuration, except in 
children who are old enough to walk (Coutts). Osteophytic lesions of the 
skull are shown by symmetrical spots of thickening upon the parietal and 
frontal bones (natijonn skulls). In the long bones osteophytes are frequently 
formed. In some cases osteophytes grow from the epiphysis, and in con- 
sequence deformity and impaired function are noted and a certain amount 
of ankylosis may occur. This condition of osteophytic growth from an epi- 
physis was called by Fournier arthropathie deformant. A child with preco- 
cious hereditary syphilis is apt to die, but if it lives from six months to one 
year the symptoms for a time disappear, 
and for years the disease may be latent. 
Diagnosis is difficult after the third or fourth 
year, especially if the disease be associated 
with rickets or tuberculosis. When later 
symptoms arise they maybe various, namely: Flg - II4— Hutch,nson teeth - 

noises in the ears, often followed by deaf- 
ness; interstitial keratitis; dactylitis (specific inflammation of all the struc- 
tures of a finger); synovitis in any joint, particularly painless but marked 
symmetrical effusion in the knee-joints, with trivial functional disturbance; 
ossifying nodes; developmental osseous defects; suppurative periostitis; 
ulcerations; death of bone; falling in of the nose; nervous maladies; occa- 
sionally sarcocele, etc. In hereditary syphilis the eye-symptoms are of great 
diagnostic importance. In 212 cases of congenital syphilis Fournier found 
eye-trouble in 101. Keratitis and choroiditis are the most usual forms (Silex). 
Bone-trouble occurs in almost half of the cases, but is not often severe enough 
to cause symptoms. The tongue often shows a smooth base (Yirchow's 
sign). Hirschberg believed choroiditis to be pathognomonic. The descend- 
ants of syphilitic parents may exhibit certain pathological conditions which 
are not directly syphilitic. Fournier calls such phenomena parasyphilitic. 
Among these phenomena are arrest of development of the body at large or 
of special structures, weakness of constitution, and stigmata of degeneration. 
Diagnosis. — In the diagnosis of hereditary syphilis the condition of the 
teeth is of considerable importance: the temporary teeth decay soon, but 
present no characteristic defect. If the upper permanent central incisors are 
examined, they are often, but by no means always, found defective. Other 
teeth may show defects, but in these alone are characteristic defects likely 
to appear. In hereditary syphilis they may present an appearance of marked 




296 Tumors or Morbid Growths 

deviation from health, and are then called " Hutchinson teeth " (Fig. 114). If 
they are dwarfed, too short and too narrow, and if they display a single cen- 
tral cleft in their free edge, then the diagnosis of syphilis is probable. If the 
cleft is present and the dwarfing absent, or if the peculiar form of dwarf- 
ing be present without any conspicuous cleft, the diagnosis may still be made. 
The view that teeth of this nature prove the existence of hereditary syphilis 
and that they occur only in syphilis has been abandoned by Hutchinson him- 
self. In fact, only one-fifth of congenital syphilitics have these teeth, and 
one-third of the cases of Hutchinson teeth are in individuals free from syphilis. 
In early infancy the diagnosis of syphilis is made by the snuffles, the broad 
nose, the skin-eruptions, the wasted appearance, the sores at the mouth- 
angles, the tenderness over bones, condylomata, and the history of the parents. 
The diagnosis at a later period is made by the existence of symmetrical inter- 
stitial keratitis, choroiditis, the smooth base of the tongue, deafness which 
comes on without pain or running from the ear, ossifying nodes, white radiat- 
ing scars about the mouth-angles, sunken nose, natiform skull, deformity of 
long bones, painless inflammation of epiphyses, and Hutchinson teeth. It 
must be remembered that a child born apparently healthy and presenting 
no secondary symptoms may show bone-disease, keratitis, or syphilitic deaf- 
ness at puberty. 

Treatment. — In infants mercurial inunctions are to be used until the 
symptoms disappear, but mercury must not be forced or be continued too long 
after the symptoms are gone. There must be rubbed into the sole of each 
foot or the palm of each hand 5 grains of mercurial ointment every morning 
and night. Brodie advised spreading the ointment (in the strength of 5 j to 
the ounce) upon flannel and fastening it around the child's belly. If the skin 
is so tender that mercury must be administered by the mouth, order that gr. yj 
to gr. \ of mercury with chalk, with 1 grain of sugar, be taken three times a 
day after nursing. If tertiary symptoms appear, and in any case when the 
secondaries disappear, give gr. ss to gr. j or more of iodid of potassium several 
times a day in syrup. White advocates the continuance of the mixed treat- 
ment intermittently until puberty. Local lesions require local treatment, 
as in the adult. A syphilitic child must be nursed by its mother, as it will 
poison a healthy nurse. If the baby has a sore mouth, it must be fed from a 
bottle; and if the mother cannot nurse the child, it must be brought up on 
the bottle. For the cachexia use cod-liver oil, iodid of iron, arsenic, and the 
phosphates. 



XVII. TUMORS OR MORBID GROWTHS. 

Division.— Morbid growths are divided into (1) neoplasms and (2) 
cysts. 

Neoplasms. — A neoplasm is a pathological new growth which tends to 
persist independently of the structures in which it lies, and which performs 
no physiological function. We say that a tumor performs no physiological 
function in order to make clear that it is never a useful addition to the economy, 
but we must not imagine that the cells of a tumor are devoid of physiological 
activity. As Fiitterer ("Medicine," March, 1902) has shown, the cells of a 
carcinoma of the liver may secrete bile, and even the cells of a secondary focus 



Causes of Tumors 297 

developing in the course of hepatic carcinoma may also secrete bile. The 
cells of a tumor may be active, but this activity is not useful and does not con- 
stitute physiological function. A hypertrophy is differentiated from a tumor 
by the facts that it is a result of increased physiological demands or of local 
nutritive changes, and that it tends to subside after the withdrawal of the 
exciting stimulus. Further, a hypertrophy does not destroy the natural con- 
tour of a part, while a tumor does. Inflammation has marked symptoms : its 
swelling does not tend to persist, it terminates in resolution, organization or 
suppuration, and examination of a section of tissue under the microscope dif- 
ferentiates it from tumor. Inflammation, too, has an assignable exciting 
cause. A new growth is a mass of newly formed tissue; hence it is improper 
to designate as tumors those swellings due to extravasation of blood (as in 
hematocele), or of urine (as in ruptured urethra), to displacement of parts 
(as in hernia, floating kidney, or dislocation of the liver), or to fluid disten- 
tion of a natural cavity (as in hydrocele or bursitis). 

Classes of Tumors. — There are two classes of tumors; the first class 
includes those derived from or composed of ordinary connective tissue or of 
higher structures. These all originate from cells which are developed from 
the mesoblast. There are two groups of connective-tissue tumors: (a) the 
typical, innocent or benign, which mimic or imitate some connective tissue 
of the healthy adult human body; and (b) the atypical or malignant, which 
find no counterpart in the healthy adult human body, but rather in the im- 
mature connective tissues of the embryo. 

The second class of tumors includes those which are derived from or com- 
posed of epithelium: (a) the typical, or innocent, composed of adult epithe- 
lium; and (b) the atypical, or malignant, composed of embryonic epithelium. 

Muller's Law. — Muller's law is that the constituent elements of neoplasms 
always have their types, counterparts, or close imitations in the tissues, either 
embryonic or mature, of the human body. 

Virchow's Law. — Virchow's law is that the cells of a tumor spring from 
pre-existing cells. There is no special tumor-cell or cancer-cell. 

The starting-point of a tumor is a focus of embryonal cells, which focus 
may have originated before the person was born or may have resulted after 
birth from some disease or injury. The nature of the tumor depends first 
upon the embryonal layer from which it took origin. Connective-tissue tumors 
spring from the mesoblast; epithelial tumors spring from the epiblast or the 
hypoblast. The nature of the tumor depends also upon the stage in which the 
growth of its cells is arrested. If the cells remain embryonal, the growth is re- 
garded as malignant; if they become fully developed, it is regarded as innocent. 

The term "heterologous" is no longer used to signify that the cellular 
elements of a tumor have no counterpart in the healthy organism, but is 
employed to signify that a tumor deviates from the type of the structure from 
which it takes its origin (as a chondroma arising from the parotid gland). 
Tumors when once formed almost invariably increase and persist, though 
occasionally warts, exostoses, and fatty tumors disappear spontaneously. 
Tumors may ulcerate, inflame, slough, be infiltrated with blood, or undergo 
mucoid, calcareous, or fatty degeneration. 

Causes. — The causes of tumors are not positively recognized, those 
alleged being but theories varying in probability and ingenuity. 



298 Tumors or Morbid Growths 

The inclusion theory oj Cohnheim supposes that more embryonic cells exist 
than are needful to construct the fetal tissues, that masses of them remain in 
the tissues, and that these embryonic cells may, later in life, be stimulated 
into active growth perhaps by injury or irritations or hereditary tendency. 
In other words, Cohnheim believes that all tumors arise from embryonal 
cells which were included or imprisoned by adult cells during fetal life and 
were not used during development; or from cells which were "displaced 
from their proper relations during the process of cell differentiation in the 
embryo" (Henry Morris, "Lancet," Dec. 12,1903). The embryonic hypo- 
thesis seems to receive a certain force from the facts that exostoses do some- 
times develop from portions of unossified epiphyseal cartilage, and that 
tumors often arise in regions where there was a suppression of a fetal part, 
closure of a cleft, or an involution of epithelium (epithelioma is usual at muco- 
cutaneous junctions). This theory does not explain the origin of malignant 
tumors in scars or recent callus in parts subjected to injury or operation, etc. 
(Henry Morris). 

Durante's addition to Cohnheim 's theory does explain them. Cohn- 
heim taught that the matrix from which a tumor springs is always an ante- 
natal embryonic area. Durante says a tumor may also spring from a post- 
natal embryonic area resulting from injury of the mature tissues, lessening 
their activities chemical and physiological (Morris) and causing them to revert 
to an embryonic condition. 

Objection has been made to the Cohnheim theory on the ground that 
an embryonal matrix could not remain quiescent, but, as Henry Morris says, 
certain teeth, the female mammary gland, the larynx, and certain appendages 
of the skin may not develop until puberty (" Bradshaw Lecture," in "Lancet," 
Dec. 12, 1903). Branchial cvsts which are known to have such an origin 
are seldom seen until after puberty, and the same is true of many dermoids. 

Morris shows that congenital matrices have been shown to exist in the brain, 
tongue, eye, testicle, ovary, broad ligament, line of coalescence in the trunk 
and other places, and such matrices constitute fetal rests or vestiges. The 
same author shows that post-natal matrices may arise in the healing of a 
wound or ulcer, fistula, burns, etc. Portions of epithelium are separated, 
get placed deeply in the newly-forming tissue, become surrounded by connec- 
tive tissue, and may later take on active growth. As Ribbert points out any 
fragment of isolated and imprisoned tissue may become a tumor. 

Hereditation is extremely doubtful. S. W. Gross found hereditary 
influence by no means frequent in cancer of the breast. It is affirmed by 
some, denied by others, and doubted by a number. At most, hereditary 
influence may only predispose. Nevertheless, cases have occurred which 
cannot be explained by the term coincidence. In the celebrated "Middlesex 
Hospital case," a woman and five daughters had cancer of the left breast. 
A. Pearce Gould had charge of a woman for cancer of the left breast. The 
mother of this patient, the mother's two sisters, and two of the mother's 
cousins had died of cancer. Power reports a remarkable instance of family 
predisposition to cancer. A patient had his right breast removed for cancer 
in 1896. In 1897 cancerous glands were removed from the axilla. In 1898 
he was seen again with an irremovable recurrent growth. His father died 
of cancer of the breast. He had two brothers, one of whom died of cancer 



Causes of Tumors 299 

of the throat when sixty-five years of age, the other having died of cancer 
of the axilla when he was only twenty-four years old. Of his eight sisters, 
four died of cancer of the breast, and the two who are living both suffer from 
cancer of the breast. One sister died when an infant, and one died after 
giving birth to a child.* That there is such a thing as predisposition is 
rendered probable by the fact that out of many exposed under like conditions 
a single one may develop cancer. 

Injury and inflammation may undoubtedly prove exciting causes. A 
blow is not infrequently followed by sarcoma; the irritation of a hot pipe-stem 
may excite cancer of the lip; the scratching of a jagged tooth may cause cancer 
of the tongue; chimney-sweeps' cancer arises from the irritation of dirt in 
the scrotal creases; and warts often arise from constant contact with acrid 
materials. 

Physiological activity favors the development of sarcoma, and physiological 
decline favors the development of carcinoma. 

Parasitic Influence. — Many believe that parasites cause cancer. This 
theory does not maintain that the tumor is the parasite, but that it contains 
the parasite, although Pfeiffer and Adamciewicz did at one time assert that 
a cancer-cell is not a body-cell, but a parasite resembling an epithelial cell. 
Some facts render a parasitic origin of malignant growths not improbable; 
as, for instance, the likeness of some tumors to infective granulomata, their 
occasional secondary development in distant parts of the body, the resem- 
blance of the secondary to the primary growths, and the tenacity of their 
persistence. A parasitic origin of cancer is pointed to by its geographical 
distribution, the disease being very common in low and marshy districts, 
and Haviland ("Lancet," April 27, 1894) and others maintain that certain 
houses become infected, the disease appearing in these houses among succes- 
sive families inhabiting them. They speak of such abodes as "canccr- 
houses." 

Some surgeons believe that cancer is contagious, but most observers deny 
it. Hanau found a rat suffering with cancer and inoculated other rats from 
it. Moreau in 1894 inoculated mice from a mouse with cancer. Guelliott, 
of Rheims, believes that cancer is primarily a local infection. He believes 
this because Moreau and Hanau have inoculated it from one animal to another 
of the same species, and if this can be brought about experimentally he sees 
no reason why it cannot happen accidentally. This surgeon says that can- 
cer is very unequally distributed, that genuine cancer-centers and "cancer- 
houses" exist, and that numerous cases of accidental infection have occurred. f 
Hahn apparently succeeded in grafting cancer from one part to another on 
the same individual. Jensen and Borrell have inoculated the disease in white 
mice. Mayet, of Lyons, holds that cancer can be reproduced by grafting or 
by injection of cancer-fluid. Graf could not find "cancer-houses" after a 
careful search. J Geissler claims to have produced the disease in a dog by 
planting fragments of cancer in the subcutaneous tissue and vaginal tissue, 
but Czerny, Rosenbach, and others dispute the claim. Plimmer tells us 
that an epidemic of cancer arose among the captive white rats in the Frei- 

*Brit. Med. Jour., July 16, 1808. 

t Amer. Journal of Med. Sciences, June, 1895. 

J Archiv f. klin. Chir., 1895, 1., p. 144. 



3<x> Tumors or Morbid Growths 

burg Pathological Institute and in each case the growth was on the rear part 
of the body. Roswell Park believes that Gaylord has really produced adeno- 
carcinoma in the lower animals. Hauser disputes the assertion that cancer 
must be an infectious disease because it is followed by secondary growths. 
Secondary growths in an infectious disease are caused by the bacterium; 
secondary growths in cancer are caused by the transference of cells of pri- 
mary growth.* Hauser says with truth that the close connection between 
innocent and malignant growths renders the parasite view untenable, because 
to hold it we would be forced to believe that every tumor has a special para- 
site or that one parasite may cause many kinds of tumors. 

There seems to be no doubt that autotransference of cancer can occur, 
although it rarely does so. Sippel has reported a case in which vaginal 
carcinoma developed at the point where the vagina was in contact with a pre- 
existing cancer of the portio.f Cornil has seen cancer transferred from one 
of the labia majora to the other, and from one lip to the other. Geissler was 
unable to transplant cancer, and Gratia also failed in his attempts. Duplay 
and Bazin say that transmissibility is possible, but only under conditions which 
are not practically realized. The facts that transplantation can be sometimes 
carried out, and that contagion is a possible occurrence under exceptional 
circumstances, do not prove that cancer is a parasitic disease, but simply 
prove that it can be transplanted. It is not that the cancer carries a parasite 
which will cause the disease in sound tissues, but rather that the cells of the 
cancer may themselves take root and grow in sound tissues. The para- 
sitic theory arose from observation of the metastasis which occurs during the 
progress of the disease, and received support from the fact that inoculation 
of another part of an individual suffering from cancer may be followed by 
the development of a tumor like the original growth. For instance, if a can- 
cer is growing upon the lower lip, the upper lip may be inoculated (contact 
cancer). The same it true of the labia. Mr. Harrison Cripps reported the 
occurrence of cancer of the skin of the arm from contact with an ulcer- 
ating scirrhus of the breast. It has also been pointed out that carcinoma is 
especially common in regions predisposed by their situation to injury and 
infection, and that, "among the lower animals at least, tumors resembling 
carcinomas have been transplanted from one to another " (" Recent Studies 
upon the Etiology of Carcinoma," by Joseph Sailer, "Phila. Med. Jour.," 
June 7, 1902). But there is great doubt as to the cancerous nature of some 
of the tumors which have been successfully transplanted from one animal to 
another. 

In successful transplantations there is as yet no proof that epithelial cells 
were not transferred with the supposed parasites, and if they were transferred 
the success of the experiment does not prove that cancer is due to parasites, 
but simply proves again what we knew before — that epithelial cells can be 
transplanted. Many parasites have been regarded as causative by different 
observers. Bacteria, yeast-cells, and protozoa have been found by different 
experimenters. It is not thought that bacteria are causative. Yeasts are 
regarded as causative by some. It is certain that they may exist in cancer, 
but it is by no means certain that they cause the disease. They may be only 

* Hauser, in Biolog. Centralbl., Oct. 1, 1895. 
f Centralbl. f. Gynak., No. 4, 1894. 



Malignant and Innocent Tumors 301 

a contamination. Gaylord and others regard the protozoa as causative, but 
this statement does not seem to be proved. Many of the supposed parasites 
of cancer have been shown to be cell-degenerations or contaminations. We 
are justified in concluding that the parasitic origin is not as yet proved, and we 
agree with the elder Senn that it is improbable. 

Tillmanns elaborately discussed the subject of cancer in the Congress of 
1895. His conclusions seem most sound and scientific. He says there is 
no evidence of a bacterial origin of cancer. The parasitic origin has not been 
proved, and protozoa have not certainly been found. Cancer can be trans- 
ferred from one part to another of the same individual, or from one indi- 
vidual to another of the same species, but never to one of a different species. 
It is possible that cancer can spread by contagion; this is very rare, but can 
happen (as when penile cancer is followed by cervix cancer in a wife). Be- 
cause it is sometimes possible to transfer cancer, this does not prove that the 
disease is parasitic or infectious; it simply shows that tissue has been success- 
fully transplanted. 

Cancer a deux is cancer developing in people who live together. Such 
cases suggest but do not prove contagion. Behla collected 19 cases and 
Guelliot 103 cases. Conjugal cancer is classified as cancer a. deux. Conjugal 
cancer is probably due to irritation or implantation and not to microbic 
inoculation. 

Actinomycosis, long thought to be a true tumor, is now known to arise 
from the ray-fungus. Some think that psorosperms cause cancer. There 
can be no doubt that changes in the liver which practically constitute a new 
growth can arise from the growth of a cell called by Darier the "psorosperm. " 
A disease due to psorosperms is called a "psorospermosis." It is affirmed 
by some that molluscum contagiosum, follicular keratosis, cancer, and Paget's 
disease are due to psorosperms. Some claim to find the parasite in all cases 
of cancer, while others can find it in only 4 or 5 per cent, of the cases. 

Heneage Gibbes affirms* that dilatation of the bile-ducts of a rabbit's 
liver is caused by the chronic irritation arising from multiplication of the coc- 
cidium oviforme in them, and not in the columnar cells of the bile-ducts, as has 
been stated; and, further, that the large majority of glandular cancers show 
nothing that can be considered parasitic, the suspicious appearances noted 
in some few cases being due to endogenous cell-formation. The coccidium 
oviforme is a genus of the sporozoa, class protozoa, the lowest division of the 
animal kingdom. To this case belong the monera and infusoria. (For a 
further discussion of this subject see page 331.) 

Malignant and Innocent Tumors. — Malignant growths infiltrate 
the tissues as they grow; benign tumors only push the tissues away; hence 
malignant tumors are not thoroughly encapsuled, while innocent tumors are 
encapsuled. Malignant tumors grow rapidly; innocent tumors grow slowly. 
Malignant tumors become adherent to the skin and cause ulceration; innocent 
tumors rarely adhere and rarely cause ulceration. Many malignant tumors 
give rise to secondary growths in adjacent lymphatic glands (cancer, except 
in the esophagus and antrum of Highmore, always does so; sarcoma rarely 
causes them, unless the growth be melanotic or unless it arises from the testicle 
or tonsil). Innocent tumors never cause secondary lymphatic involvement; 
* Am. Journal of Med. Sciences, July, 1893. 



302 Tumors or Morbid Growths 

although the glands near the tumor may enlarge from accidental inflammatory 
complications. The malignant tumors, especially certain sarcomata and 
soft cancers, may be followed by secondary growths in distant parts and 
various structures (bones, viscera, brain, muscles, etc.); innocent tumors are 
not followed by these secondary reproductions, although multiple fatty tumors 
or multiple lymphomata may exist. Malignant tumors destroy the general 
health; innocent tumors do not unless by the accident of position. Malignant 
tumors tend to recur after removal; innocent tumors do not if operation was 
thorough. The special histological feature of a malignant growth is the 
possession by its cells of a power of reproduction which knows no limit, the 
cells of the tumor living among the body-cells like a parasite, and invading 
and destroying the body-cells. 

Classification. — Tumors may be classified as follows: 

I. Connective-tissue tumors (those derived from the mesoblast). 

i. Innocent tumors, or those composed of mature connective tissue: 
Lipomata, or fatty tumors; fibromata, or fibrous tumors; chondro- 
mata, or cartilaginous tumors; osteomata, or bony tumors; odonto- 
mata, or tooth-tumors; myxomata, or mucous tumors; myamata, or 
muscle-tumors; neuromata, or tumors upon nerves; gliomata, or tu- 
mors composed of neuroglia; angiomata, or tumors formed of blood- 
vessels; lympliangiomata, or tumors formed of lymphatic vessels. 
The term lymphoma, meaning a tumor of a lymphatic gland, was 
formerly applied to hypertrophy and hyperplasia of a lymphatic 
gland, no matter whether caused by syphilis, tubercle, Hodgkin's 
disease, or any other morbid impression. The term has been 
largely abandoned except as expressing enlargement of a gland, 
and does not convey any suggestion as to the cause. It is doubtful 
if there is such a thing as a true lymphoma, understanding by the 
term a neoplasm arising from and composed of lymphoid cells and 
resembling lymphatic structure. In the described cases the possi- 
bility of infection as a cause has not been eliminated. 
2. Malignant tumors, or those composed of embryonic connective tissue: 
Sarcomata and adrenal tumors. 

Endotheliomata are regarded by some as constituting an independent 
group and by others as a variety of sarcomata. 

II. Epithelial tumors (those derived from the epiblast or hypoblast), 
i. Innocent tumors, or those composed of mature epithelial tissue: 

Adenomata, or tumors whose type is a secreting gland; and papillo- 
mata, or tumors whose type is found in the papillae of skin and 
mucous membranes. 
2. Malignant tumors, or those composed of embryonic epithelial tissue: 
Carcinomata, or cancers. 

III. Cystomata are cystic tumors, the cyst-wall of which are new growths 
and the contents of which are produced by the cells of the newly 
formed cyst-walls. 

IV. Teratomata (tumors containing epiblastic, hypoblastic, and meso- 

blastic elements). 
Innocent Connective=tissue Tumor.— These growths mimic or imi- 
tate some connective tissue or higher tissue of the mature and healthy organism. 
Lipomata are congenital or acquired tumors composed of fat contained 



Lipomata 



3°3 



in the cells of connective tissue, which cells are bound together by fibers. If 
the fibers are excessively abundant, the growth is spoken of as a fibrojattv 
tumor. A fatty tumor has a distinct capsule, tightly adherent to surrounding 
parts, but loosely attached to the tumor; hence enucleation is easv. Fibrous 
trabecular run from the capsule of a subcutaneous lipoma to the skin; hence 
movement of the integument over the tumor or of the tumor itself causes 
dimpling of the skin. An ordinary circumscribed lipoma is of doughy soft- 
ness, is lobulated, of uniform consistence, and on being tapped imparts to the 
finger a tremor known as pseudofluctuation. A fatty tumor is mobile, although 
it may be attached to the skin at points by trabecular. Lipomata are most 
frequent in middle life, and their commonest situations are in the subcutaneous 
tissues, especially of the back or of the dorsal surfaces of the limbs; they 
usually occur singly, but may be multiple and sometimes symmetrical. Senn 
described the case of a woman who had 
a fatty tumor in each axilla. A lipoma 
may grow to an enormous size (in 
Rhodius's case the tumor weighed sixty 
pounds) , and the growth may be pro- 
gressive or may be at times stationary 
and at other times active. The skin 
over a fatty tumor sometimes atrophies 
or even ulcerates; the tumor itself 
may inflame or partly calcify. When a 
lipoma has once inflamed it becomes 
immovable. Subcutaneous lipoma 
of the palm of the hand or sole of the 
foot bears some resemblance clinically 
to a compound ganglion; it is apt to 
be congenital. Lipomata of the head 
and face are rare. In the subcutane- 
ous tissues of the groins, neck, pubes, 
axillae, or scrotum a mass of fat may 
form, unlimited by a capsule and known 
as a "diffuse lipoma" (Fig. 115). A 
diffuse lipoma may dip down among 
the muscles. Such masses attain large size. The typical diffuse lipoma is 
occasionally seen on the neck. It begins back of the mastoid process on one 
side or on both sides. When large, it completely surrounds the neck, a huge 
double chin forming in front, a great mass hanging on each side, and the 
posterior portion being divided into two halves by a median depression. A 
nrvolipoma is a nevus with much fibrofatty tissue. A very vascular fatty 
tumor is called lipoma telangiectodes. If the tumor stroma contains large 
veins, the growth is called a cavernous lipoma. A tumor containing much 
blood can be diminished in size by pressure. Fatty tumors may arise in the 
subserous tissue, and when such a growth arises in either the femoral or inguinal 
canal or the linea alba it resembles an omental hernia and is spoken of as a 
fat-hernia. In the retro-peritoneal tissues enormous fibrofatty tumors occa- 
sionally grow, and these neoplasms tend to become sarcomatous. Lipomata 
may arise from beneath synovial membranes and will project into the joints, 




Fig. 115. — Diffuse lipoma. 



3°4 



Tumors or Morbid Growths 



being still covered by synovial membrane. Fatty tumors occasionally arise 
in submucous tissues, between or in muscles, from periosteum, and from the 
meninges of the spinal cord (J. Bland Sutton). A fatty tumor may undergo 
metamorphosis. The stroma may be attacked by a myxomatous process or a 
calcareous degeneration. The fat-cells themselves may become calcareous. 
Oil-cysts sometimes form. A xanthoma is a growth composed of fatty tissue in 
and about which there is marked infiltration with small cells. Such a tumor 
is flattened and slightly elevated. Several or many of these growths occur 
in the same person. The eyelids are the most common seat of xanthoma. 
The tumor may undergo involution or may become sarcomatous. 

Diabetics are liable to develop xanthomata. 

Treatment. — A single subcutaneous lipoma should be extirpated. The 
capsule must be incised, when the tumor can be torn out forcibly or can be 




Fig. 116. — Fatty tumor. 

enucleated by dissection; drainage is always employed for twenty-four hours, 
as butyric fermentation will be apt to occur, and necrosis of small particles 
of fat predisposes to infection. Multiple subcutaneous lipomata, if very 
numerous, should not be interfered with unless troublesome because of their 
size or situation, when the growth or growths causing trouble should be 
removed. It is difficult to extirpate entire a diffuse lipoma, and several opera- 
tions may be needed to effect complete removal. Liquor potassae, once recom- 
mended as possessing power, when taken internally, to limit the growth of 
multiple lipomata or diffuse lipoma, seems to be useless. Subperitoneal 
lipomata are rarely diagnosticated until the belly has been opened or the 
growth has been removed. 

Fibromata are tumors composed of bundles of fibrous tissue. There 
are two forms, the hard and the soft. A hard fibroma consists of wavy fibrous 
bundles lying in close contact. Here and there connective-tissue corpuscles 



Fibromata 305 

exist between the fibers. A fibroma has no distinct capsule, though surround- 
ing tissues are so compressed as to simulate a capsule. Fibromata are occa- 
sionally congenital, are most usual in young adults, but they may occur at any 
period of life, and in any part of the body containing connective tissue. Pure 
fibromata, which are rare, are generally solitary, grow slowly, are of uniform 
consistence, have not much circulation, and are hard and movable. Fibro- 
mata may form upon nerves, they may arise in the mammary gland, they may 
develop in the lobe of the ear, and they may spring from various fibrous mem- 
branes, from the periosteum of the base of the skull (nasopharyngeal fibro- 
mata), and from the gums (fibrous epulides). A soft fibroma contains much 
areolar tissue, the spaces of which are filled with fluid, so that the tissue seems 
edematous. Soft fibromata grow from the skin, mucous membranes, sub- 
cutaneous tissue, intermuscular planes, and periosteum. Soft fibromata are 
especially apt to arise from the skin of the scrotum, labia, inner surface of 
arm and thigh, and of the belly wall of a pregnant woman. They are not un- 
usually multiple, grow slowly, but more 
rapidly than the hard fibromata, and 
may become quite large and possess 
distinct pedicles. Fibromata may be- 
come cystic, calcareous, osseous, col- 
loidal, or sarcomatous, and may inflame, 
ulcerate, or even become gangrenous. 

A pain Jul subcutaneous tubercle, 
which is a form of fibroma commonest 
in females, arises in the subcutaneous 
cellular tissue, usually of the extremities. 
It is firm, very tender, movable, rarely 
larger than a pea, and the skin over it 
seems healthy. Violent pain occurs in 
paroxysms and radiates over a con- 
siderable area, of which the tubercle fcV-X 
is the center. These paroxysms may Fig . II7 ._Keioid following a bum. 

occur only once in many days or many 

times in one day. Pain is always developed by pressure, and may be linked 
with spasm. Nerve-fibrilke are now known to exist in these tubercles, a fact 
which was long denied. 

A mole is a fibroma of the skin which is congenital or appears in the early 
weeks of life. It is rounded or flat, is usually pigmented and of a brown color, 
is slightly elevated above the cutaneous level, and has a few hairs or an abun- 
dant crop of hair growing from it, and varies in size from a pin's head to 
several inches in diameter, or may even occupy an extensive area of a limb or 
of the trunk. The tumor rarely grows after the thirteenth or fourteenth year. 
A mole may become malignant, melanotic carcinoma may arise from its 
epithelial structures, or melanotic sarcoma from its connective-tissue ele- 
ments. A mole is an extremely vascular structure; it bleeds freely when cut 
or scratched, and it sometimes ulcerates. Occasionally several or many moles 
exist in the same individual. If a mole begins to increase rapidly in size, 
operation is imperative, as rapid growth probably indicates malignant change. 

Fibrous epulis is a fibroma arising from the gums or periodontal membrane 




306 Tumors or Morbid Growths 

(J. Bland Sutton) in connection with a carious tooth or retained snag; it is 
covered by mucous membrane, grows slowly, may attain a large size, and 
sometimes has a stem, but is more often sessile. It may undergo myxo- 
matous change or may become sarcomatous. 

Fibrous tumors may arise from the ovary, the intestine, and the larynx. 
Pure fibromata of the uterus are very rare, but fibromyomata are very com- 
mon (see Myomata, page 310); hence the term "uterine fibroid" should be 
abandoned. 

Molluscum fibrosum is an overgrowth of the fibrous tissue of both the skin 
and the subcutaneous structure. Senn excludes this form of growth from 
consideration with fibromata because of its supposed infective origin. It may 
be limited or widely extended; it may appear as an infinite number of nodules 
scattered over the entire body or as hanging folds of fibrous tissue in certain 
areas. Keloid (Fig. 117) is a fibroma of the true skin. It is a hard, fibrous, 
vascular growth, with a broad base, arising in scar-tissue; it is crossed by 
pink, white, or discolored ridges, and is named from a fancied likeness to the 
crab. It has rarely attacked mucous membrane. It is more common in 
negroes than in whites, and is most frequent in the cicatrices of burns, though 
it may arise in the scar of any injury, as the scar from piercing the ears, and 
in the scars of syphilitic lesions, tuberculous processes, smallpox, or vaccina- 
tion. It is rare in early childhood and in old age. It grows slowly, lasts for 
many years, and may eventually undergo involution and disappear. It is 
almost useless to remove keloid by operation, as it will usually return, yet 
a study of the growth removed shows no reason for the inevitable return. 
The fibrous tissue of keloid springs from the outer walls of the blood-vessels 
(Warren). The papillae of the skin above the tumor are destroyed or replaced 
by fibrous tissue. 

Morphea, spontaneous or true keloid, is a name used to designate a growth 
of this description which does not arise from a scar; but it seems certain that 
scar-tissue was present, though possibly in small amount from trivial injury. 
The fact that keloid is especially common in the negro race (a race predis- 
posed to tuberculosis) and that it is so frequently met with in the scars of 
known tuberculous processes, suggests the possibility of a tuberculous cause 
for the condition. The rapid return of keloid after operation suggests a 
near or distant infection which furnishes material to a point of least resist- 
ance which causes keloid to redevelop. Some cases of keloid have active tuber- 
culous lesions, others have had them, in still others latent or distant lesions 
may be found by careful search. In many cases there is a family history 
of tuberculosis. I am at present investigating this important matter. It 
is certain that the keloid itself does not contain bacteria. Repeated exami- 
nations have failed to find them. It is quite possible that the growth con- 
tains toxins of tubercle bacilli, the toxins being the irritant cause. I am now 
seeking to determine if material from keloid introduced into tuberculous 
animals will cause a reaction, and if a reaction follows the injection of tuber- 
culin into the victims of keloid. 

Fibrous and papillomatous growths covered with endothelium may spring 
from any serous membrane. Such a growth of the choroid plexus calcifies 



Chondromata 307 

early and constitutes a psammoma or brain-sand tumor. Such tumors are 
met with not only in the choroid plexus, but also in the conarium and the dura. 
All psammomata are not fibrous; some are gliomatous and some are endo- 
theliomatous. A cholesteatoma is a fibrous growth covered with endothelium 
and containing layers of crystalline fat. It occurs especially in the pia mater, 
but may arise in either of the other membranes or even in the brain substance, 
and is called a pearl tumor. 

Treatment. — When in accessible regions fibromata should be enucleated. 
Fibromata should not be let alone, because any fibrous tumor may become a 
sarcoma. If a hard fibroma of the skin exists the skin is incised and the tumor 
is "shelled out." A soft fibroma is removed by an incision carried round the 
base of its pedicle. A painful subcutaneous tubercle should be excised. If 
a mole shows the slightest disposition to enlarge, or if it is subjected to pressure 
or irritation, it should be removed, because if allowed to remain it might 
develop into a malignant growth. It is often desirable to remove a hairy or 
pigmented mole, not only because it may become malignant, but also because 
it is unsightly. Fibrous epulis requires the cutting away of the entire mass, 
the removal of the related snag or carious tooth, and sometimes the biting 
away of a portion of the alveolus with rongeur forceps. A naso-pharyngeal 
fibrous polyp usually contains sarcomatous elements or becomes a spindle- 
cell sarcoma. If it has a pedicle, it may be removed by the cautery loop. In 
a severe case a part of the superior maxillary bone is removed by osteoplastic 
resection to permit of extirpation. Keloid should rarely be operated upon: 
it will only return, and will also recur in the stitch holes. Trust to time for 
involution, or use pressure with flexible collodion, by which method J. M. 
DaCosta cured a case following smallpox. It may be necessary to operate 
because of ulceration. If it is necessary to operate, remove the keloid and 
considerable adjacent tissue and fill the gap with Thiersch grafts. The 
administration of thyroid extract may be of benefit (a gr. v tablet three or four 
times a day). This drug must be given cautiously, as it may cause attacks 
characterized by fever, dyspnea, and rapid pulse. Thiosinamin hypoder- 
matically has been used, it is claimed, with benefit. A 10 per cent, solution 
is made, and from 10 to 15 minims can be injected into the gluteal muscles 
every third day. I have seen two keloids cured by the use of the x -rays. 

Chondromata (enchondromata) are tumors formed either of hyaline 
cartilage, of fibrocartilage, or of both. Chondromata are apt to arise from 
certain glands, the long bones, the pelvis, the rib cartilages, and the bones of 
the hands or feet, and often spring from unossified portions of epiphyseal 
cartilage. They may be single or multiple, and are most commonly met with 
in the young. They have distinct adherent capsules; they grow slowly, and 
if of osseous origin progressively' hollow out the bones by pressure; they cause 
no pain; they impart a sensation of firmness to the touch, unless mucoid 
degeneration forms zones of softness or fluctuation ; they are inelastic, smooth 
or nodular, immovable, and often ossify. A chondroma may grow to an 
enormous size. A chondroma of the parotid gland or testicle practically 
always contains sarcomatous elements, and any chondroma may become 
a sarcoma. Chondromata are notably frequent in persons who had rickets 
in early life. Ecchondroses, which are "small local overgrowths of car- 
tilage" (J. Bland Sutton), arise from articular cartilages, especially of 



308 Tumors or Morbid Growths 

the knee-joint, and from the cartilages of the larynx and nose. Loose or 
floating cartilages in the joints may be broken-off ecchondroses or portions 
of hyaline cartilage which are entirely loose or are held by a narrow stalk, and 
which arise by chondrification of villous processes of the synovial membrane; 
only one or vast numbers may exist; one joint may be involved, or several; 
they may produce no symptoms, but usually produce from time to time violent 
pain and immobility by acting as a joint- wedge. An ecchondroma may arise 
within the medullary canal of a long bone, from foci of dormant cartilage, and 
may lead to the development of a solitary cyst of large size by softening of the 
tumor. The femur is the most usual site of disease. It begins very insidiously 
and progresses gradually. There are slight lameness, trivial pain, tenderness 
below the level of the trochanter, apparent shortening and some bulging of 
bone. The bone may bend or at some spot may thin so that the cyst can be 
felt. Such a bone fractures from slight force, and after a fracture, when the 
effused blood and inflammatory exudate have been absorbed, a tumor can 
be distinctly detected. A solitary cyst of a long bone is apt to be regarded 
clinically as a sarcoma (Bergmann-Virchow). 

Treatment. — Remove chondromata whenever possible, for, if allowed 
to remain undisturbed, they are apt to resent this hospitality by becoming 
sarcomatous. Incise the capsule and take away the growth, using chisels 
and gouges if necessary. Incomplete removal means inevitable recurrence. 
Amputation is very rarely demanded. Loose bodies in the joints, if produc- 
tive of much annoyance, are to be removed, the joint being opened with the 
strictest antiseptic care. Amputation is sometimes performed for a solitary 
cyst of a long bone, the surgeon having looked upon the growth as sarcoma- 
tous. If a correct diagnosis is arrived at, an attempt should be made to 
remove the cyst without amputation. Bergmann succeeded in extirpating 
such a mass from the femur. 

Osteomata. — Osteomata are tumors which are composed of osseous 
tissue. J. Bland Sutton says that osteomata are ossifying chondromata. 
Osteomata take origin from bone, cartilage, connective tissue, especially 
tissue near the bone, serous membrane, and certain glands and organs. Com- 
pact osteomata, which are identical in structure with the compact tissue of 
bone, arise from the frontal sinus, mastoid process, external auditory meatus, 
and other regions in those beyond middle life; they are small, smooth, round, 
densely hard, with small and occasionally cartilaginous bases. 

Cancellous osteomata, which comprise the great majority of bone-tumors, 
are similar in structure to cancellous bone. They spring from, and are crusted 
with, cartilage; they may have fibrous capsules, and are often movable when 
recent, but soon become fixed; they have broad bases, are angled, nodular, 
firm (but not so hard as are the compact osteomata), painless except when 
pressed, occur particularly at the ends of long bones, may grow to large size, 
and are commonest in youth. Osteomata near joints become overlaid by 
bursa?, which in rare instances communicate with an adjacent joint. 

The term exostosis has been used as being synonymous with osteoma, but 
wrongly so, as an exostosis is an irregular, local, bony growth which does not 
tend to progress without limit, and which is, hence, not a tumor. A true exos- 
tosis is seen in the ossification of a tendon-insertion, in a limited growth from 
one of the maxillary bones, and in a local growth from the last phalanx of the 



Myxomata 309 

big toe, which latter form of growth is known as a subungual exostosis. Ex- 
ostoses of the retrocalcaneal bursa occasionally arise when this bursa is inflamed. 
Inflammation of this bursa is known as Achittodynia or Albert's disease. The 
bony masses sometimes found in the brain, lungs, testicle, various glands, 
and tumors are not true osteomata. Osteomata do not tend to become 
malignant and do not recur after removal. 

Treatment. — Osteomata which are non-productive of pain or trouble 
do not demand removal. If they produce pain by pressure, if they press upon 
important structures, if they cause annoying deformities, or if they grow 
rapidly, then remove them by means of chisels, gouges, or the surgical engine. 
Subungual exostosis should always be removed. The nail should be split 
and part of it taken away, and the bony mass be gouged away or be cut off 
with forceps. 

Odontomata * are tumors composed of tooth-tissue. They spring from 
the germs of teeth or from developing teeth. J. Bland Sutton divides them 
into (1) those springing from the follicle; (2) those springing from the papilla; 
and (3) those springing from the whole germ. 

Epithelial odontomes, or multilocular cystic tumors, arise from the 
follicle, occur offenest in the lower jaw, dilate the bone, have capsules, and 
are made up of masses of cysts which are filled with brown fluid. These 
cysts are met with most frequently before the age of twenty. Follicular odon- 
tomes, or dentigerous cysts, oftenest spring from the follicles of the permanent 
molars. In a dentigerous cyst there exists an expanded follicle which dis- 
tends the bone, the follicle being filled with thick fluid and containing a portion 
of a tooth. A fibrous odontome is due to thickening of the tooth-sac, which 
prevents eruption of the tooth; fibrous odontomes are usually multiple, and 
are apt to occur in rickety children. A cementome is due to enlargement, 
thickening, and ossification of the capsule, the developing tooth being encased 
in cement. A compound follicular odontome is due to ossification of portions 
only of an enlarged and thickened capsule, and the tumor contains bits of 
cementum, portions of dentine, or small misshapen teeth. A radicular 
odontome springs from the papilla and arises after the crown of the tooth is 
formed and while the roots are forming; hence it contains dentine and cement, 
but no enamel. Composite odontomes are formed of irregular, shapeless 
masses of dentine, cement, and enamel. All the above forms occur in man. 
They present themselves as hard tumors associated with teeth or in an area 
where teeth have not erupted. Occasionally an odontome simulates necrosis; 
it is surrounded by pus, and a sinus forms. 

Treatment. — The diagnosis is scarcely ever made until after an incision; 
hence, be in no haste to excise large portions of bone for a doubtful growth; 
incise first and see if it be an odontome, which requires only the removal of 
an implicated tooth, curetting with a sharp spoon and packing with iodo- 
form gauze. 

Myxomata are tumors composed of mucous tissue. They are rare as 
independent growths, although myxomatous change is frequent in the stroma 
of other tumors. The tissue type of these tumors is found in the vitreous 
humor of the eye and in the perivascular tissues of the umbilical cord (Whar- 

*This section is abridged from J. Bland Sutton's striking chapter upon odontomes in 
his recent work on " Tumors." 



310 Tumors or Morbid Growths 

ton's jelly). Bowlby states that myxomata are in reality soft fibromata whose 
intercellular substance has been replaced by mucin. The myxomatous state 
may be a stage in the formation of a fibroma, a stroma not having developed. 
Myxomata may result from myxomatous degeneration of cartilage, of muscle, 
or of fibrous tissue. These tumors are soft, elastic, usually pedunculated, 
tremulous, and vibratory. The stroma is very delicate and carries minute 
blood-vessels. Cutting into a myxoma causes a straw-colored, clear jelly 
to exude. Myxomata grow slowly, are encapsuled, have but little circulation, 
and the diagnosis may be impossible before removal of the growth. Some 
pathologists place myxomata among the malignant tumors, but most consider 
them as benign tumors, though they tend strongly to become sarcomatous 
(rnyxosarcomata) . A sarcoma may undergo myxomatous degeneration. 

Myxomata may arise from the skin; from the mucous membrane of the 
nose, the frontal sinus, the antrum, the womb, the auditory meatus, and the 
tvmpanum (gelatinous polyps); from the parotid and mammary glands; 
from the subcutaneous tissue, the nerve-sheaths, the intermuscular septa, 
the rectum, and the bladder (polyps). They may be congenital, but occur 
most often in young adults, as a result of inflammation. A sudden increase 
of growth indicates beginning malignancy (sarcomatous - change). When 
a tumor begins to undergo myxomatous transformation we give to it a com- 
pound name; for instance, a chondroma undergoing myxomatous change is 
a chondromyxoma, a fibroma undergoing a like change is a fibromyxoma, etc. 
Mucous polypi grow from the mucous membrane of the nose, particularly 
from the outer wall near the middle turbinated bone, and often from the roof 
of the nares. Mucous polypi are soft and jelly-like, of a grayish color, and 
have stems or pedicles; they may be seen through the anterior nares, may 
project behind the veil of the palate, and may bulge out from the passages of 
the nose; they may be, and usually are, multiple; they may be present in one 
nasal fossa or in both; and they occur most commonly in youths and adults 
between the ages of fifteen and thirty-five years. 

Hydatid moles of pregnancy are due to myxomatous changes in the chorion. 

Treatment. — In treating myxomata, remove them promptly and thor- 
oughly, because of the danger of sarcomatous change. Polyps of the bladder 
are removed by means of cutting forceps after suprapubic cystotomy has been 
performed. Nasal polyps may usually be twisted off or be removed by the 
wire snare or galvanocautery. Occasionally when the growths are numerous 
and recur rapidly after removal, the inferior turbinated bones should be re- 
moved with a saw (Rouge's operation). This operation secures ready access 
to the area of disease, which can be attacked radically. A very soft myxoma 
breaks up when removal is attempted, and the base must be cauterized. 

Myomata are tumors composed of unstriped muscle-fiber mixed often 
with fibrous tissue. They are called liomyomata. Tumors composed of 
striated muscle-fiber and spindle-cells are known as rhabdomyomata. They 
are very rare and are always sarcomatous. Liomyomata are found in the 
womb, in the prostate gland, in the walls of the gullet, vagina, stomach, 
bladder, and bowel, in the broad ligament, ovary, and round ligament, in the 
scrotum, and in the skin. Myomata usually begin during or after middle 
age; they are encapsuled, they grow slowly, they are firm and hard, and 
produce annoyance by their size and weight or by obstructing a viscus or 



Myomata 311 

channel. A liomvoma of the posterior portion of the middle of the prostate 
gland is known as a " middle lobe." 

The so-called uterine fibroid is a myoma or fibromyoma. Uterine myo- 
mata may originate within the walls of the womb (intramural myomata), 
from the muscular structure of the mucous lining (submucous myomata), or 
from the muscular tissue of the serous covering (subserous myomata). Intra- 
mural uterine myomata may be single or multiple and may grow to an enor- 
mous size. Submucous myomata project into the cavity of the womb (fleshy 
polyps), and may project into the vagina. They distend the uterus and are 
often accompanied by menorrhagia or metrorrhagia. In some rare cases the 
projecting tumor is detached by Nature and the patient is cured; in some cases 
the myoma becomes gangrenous. A fleshy polyp may produce inversion of 
the fundus of the womb. Subserous uterine myomata cause trouble only by 
the inconvenience of weight or the discomfort of pressure. Uterine myomata 
are commonest in single women, and arise most frequently between the ages 
of twenty-five and forty-five. Xegro women are especially prone to develop 
such tumors. They may never produce any symptoms. Some of these 
growths, by enlarging until they ascend above the pelvic brim, produce 
abdominal distention; some become jammed or impacted in the pelvis, and 
produce by pressure retention of urine, obstruction to the passage of feces 
or hydronephrosis. Impaction may occur temporarily at each menstrual 
period. Many myomata produce uterine hemorrhage; some cause retro- 
version of the womb ; some protrude from the cervical canal ; some are so large 
that they cause disastrous pressure upon the colon (obstruction), upon the 
iliac veins (great edema), or upon the ureters (hydronephrosis). Uterine 
myomata usually shrink after the menopause. Pregnancy in a myomatous 
womb usually ends in abortion. Uterine myomata mav undergo fatty, 
calcareous, or myxomatous change, and may be infected by septic organisms 
as a result of the use of a uterine sound or of infection of the pedicle after 
oophorectomy. Infection of a uterine myoma causes great enlargement, 
elevated temperature, sweats, and exhaustion. 

The symptoms of myomata of the alimentary canal are similar to or 
identical with the symptoms of malignant growths. Myomata of the skin 
are rare growths; they are encapsuled, firm or elastic, and painless. 

Treatment. — Cutaneous myomata are removed in the same manner as 
fibrous tumors. Uterine myomata are treated by rest and the administration 
of ergot, barium chlorid, and dilute sulphuric acid. If this treatment fails 
to arrest serious bleeding due to a flesh polyp, dilate the cervical canal and 
remove the growth. If there be dangerous bleeding in a woman who has 
some years to wait for the menopause and who has not a removable polyp as 
the cause, perform oophorectomy in order to bring on an artificial menopause. 
W hen a myoma becomes impacted at each menstrual period, remove the ovaries 
and Fallopian tubes. Subserous myomata may be removed from the uterus 
after abdominal section, the resulting wound in the uterus being sutured. 
Hysterectomy is indicated for some very large tumors, for tumors that grow 
after the menopause, and for infected myomata. If the abdomen be opened 
to perform oophorectomy, and the tubes and ovaries are found so implicated 
in the growth that they cannot be removed completely, or the broad ligament 
is found so drawn out that a safe pedicle cannot be secured, perform a hyster- 



312 Tumors or Morbid Growths 

ectomy.* A recent suggestion for the shrinkage of uterine myomata is to 
ligate both the uterine and ovarian arteries. If a myoma of the prostate causes 
severe obstruction, perform a suprapubic cystotomy and remove the major 
portion of the enlarged gland; or make both a suprapubic and a perineal 
opening, push the gland into the perineum and shell it out with the finger, or 
make permanent suprapubic drainage. 

Neuromata. — A true neuroma springs from nerve-tissue (brain, cord, or 
nerve-trunks) ; it is composed of medullated or non-medullated nerve-fibers 
which form a plexus or network, and which are not continuous with the fibers 
of the nerve-trunk or other area from which the tumor grows. True neuro- 
mata, which are rare growths, arise during middle life; they are small in size; 
are due to injury or hereditary tendency, and they may be single or multiple. 
There is usually around the tumor, rather than in it, severe neuralgic pain, 
which is greatly intensified by dampness, by blows, or by rough handling. 
The parts below a neuroma are cold, swollen, often anesthetic, and frequently 
present motor paralysis or trophic disorder. A false neuroma or neurofibroma 
is a fibrous tumor growing from a nerve-sheath, and is identical in structure 
with the sheath. False neuromata may be single, but they are often multiple; 
they may be as small as peas or as large as oranges; they are smooth and 
movable, and may cause great pain or may be painful only when pressed or 
struck; they may spring from roots, trunks, or branches, and they may be 
linked with the disease known as " molluscum fibrosum." In plexiform 
neuroma some branches of a nerve enlarge and lengthen like an artery in a 
cirsoid aneurysm ; the mass feels like beads or like a bag of worms ; it is mobile, 
and no pain is felt on moving it; and it is generally congenital. In plexiform 
neuroma the nerve-sheath undergoes myxomatous change. Malignant 
neuroma is a primary sarcoma of a nerve-sheath, though any neuroma may 
become sarcomatous. 

Traumatic neuromata are false neuromata and are occasionally well ex- 
hibited after nerve-section or amputation. On nerve-section the distal end 
shrinks and atrophies, the proximal end enlarges and becomes bulbous. A 
traumatic neuroma is composed of fibrous tissue which contains nerve-fibers. 
Such a growth is usually, but not always, painful on pressure or during damp- 
ness, and is most commonly seen in a stump which did not heal by first inten- 
tion. In performing an amputation cut the nerves high up, and thus keep 
them out of the scar, permit them to remain mobile in their sheaths, and so 
prevent a tender stump. A tender stump may be due to anchoring of a nerve 
in a scar, the nerve ceasing to glide when the individual moves the extremity. 
The condition known as painful subcutaneous tubercle was discussed on page 

3°5- 

Treatment. — A false neuroma is to be removed, if possible, without de- 
stroying the nerve-trunk. If, in removing a neuroma, it is necessary to exsect 
a portion of a nerve-trunk, always endeavor to suture the ends of the divided 
nerve so as to facilitate restoration of function. For multiple neuromata — at 
least should the number be large or should molluscum fibrosum exist — surgery 
can do nothing. Plexiform neuromata may often be removed, but amputation 
may be required. Painful neuromata in stumps should be excised. 

* See J. Bland Sutton's admirable article on "Uterine Myomata" in his work on 
"Tumors." 



Angiomata or Hemangiomata 313 

Gliomata. — These tumors develop from neuroglia and more often from 
the white substance than from the gray. They are usually single, and arise 
in the brain, rarely in the cord, and very rarely in the cranial nerves. They 
may take origin in one of the cerebral hemispheres, in the cerebellum, in the 
pons, or in the medulla. Some gliomata are soft and bear a close relationship 
to sarcoma ; others are hard and resemble fibroma. 

A glioma is a circumscribed growth in contrast to a gliosis, which is a 
widespread and unlimited hyperplasia of the neuroglia. Syringomyelia is 
due to gliosis of the spinal cord. 

"A glioma consists of cells containing rounded or oval nuclei with very 
little protoplasm and fine protoplasmic extensions which interlace and form 
an intercellular reticulum" (Stengel). 

A glioma passes almost insensibly into surrounding tissue, and there is no 
distinct edge; hence, because of the slight differentiation from brain sub- 
stance, it may be overlooked during exploration. It is harder than the sur- 
rounding tissue; is vascular and of a pink or red color; and the normal 
shape of the part is often very little altered, although the tumor may reach 
the size of a lemon. 

Hemorrhage may take place into a glioma, softening may occur, cavities 
may form, or the growth may become sarcomatous or psammomatous. The 
symptoms of a glioma of the brain depend on the situation. 

Treatment. — When the growth can be localized it is justifiable in some 
cases to attempt its removal. Even a partial removal may be of benefit. 

Angiomata or Hemangiomata. — An angioma is a tumor composed 
largelv of dilated blood-vessels. The older surgeons called such growths 
erectile tumors. Some of the so-called angiomata are not genuine new growths, 
but are due to dilatation and elongation of blood-vessels. 

Simple or capillary angiomata, nevi, or " mother's marks," which 
affect the skin or subcutaneous tissue, are composed of enlarged and twisted 
capillaries and of anastomosing vessels surrounded by fat. These growths 
are congenital or appear in the first few weeks of life; they are flat and slightly 
raised, and are of a bright-pink color if composed chiefly of arterioles, and 
are bluish if composed mainly of venules; they are but little elevated; they can 
be almost completely emptied by pressure; they occasionally pass away spon- 
taneously, but usually grow constantly and may become cavernous; they may 
ulcerate and occasion violent or fatal hemorrhage. One or several large 
vessels connect a nevus to adjacent blood-vessels. Port-wine or claret 
stains are pink or blue discolorations due to superficial nevi of the skin; they 
may be small in extent or they may involve a very large area, are not elevated, 
and do not usually spread. Telangiectasis is a form of nevus involving the 
skin and subcutaneous tissue in which many arterioles and venules exist. 
Simple angiomata are common on the forehead, the scalp, the face, the neck, 
the back, and the extremities. They may appear on the labia, the tongue, 
or the lips. 

Cavernous angiomata, or venous nevi (Fig. 118), resemble in structure 
corpora cavernosa of the penis; there are large endothelial lined spaces with 
thin walls carrying blood, and there may be distinct vessels as well. Arteries 
send blood into the spaces, and veins receive it from the spaces. These 
channels and sinuses are enormously distended capillaries. Cavernous 



3*4 



Tumors or Morbid Growths 




Fig. iiS.— Cavernous angioma and lymphangioma. 



angiomata arise in the skin and subcutaneous tissues; they are usually con- 
genital, but may develop from simple angiomata; they are purple or blue in 
color; are more distinctly elevated than the capillary nevi; may be either 
cutaneous or subcutaneous; swell when the child cries, and are apt to pulsate; 

they may be emptied by pressure, 
and often look like cysts with very 
thin walls. Cavernous angiomata 
may arise in the breast, the tongue, 
the lip, the cheek, the gums, the 
subcutaneous tissues, or the mus- 
cles. If an angioma contains an 
excess of fat, the growth is called 
a "nevoid lipoma." 

Plexiform angiomata are 
known as "cirsoid aneurysms'' 
or aneurysms by anastomosis 

(page 373)- 

Angiomata noticed soon after 
birth may disappear completely 
or may enlarge progressively. 

Treatment. — These growths 
if large or growing must be treated. 
A capillary nevus can often be 
quickly cured by touching it with 
fuming nitric acid. A second application of acid may be required. The 
growth may be destroyed by heat — "a knitting-needle at a dull-red heat or 
the galvano-cautery " (Wharton). The application of ethvlate of sodium or 
the employment of electrolysis will destroy 
the growth. Astringent injections are dan- 
gerous unless the base of the nevus is 
ligated, because they may lead to the for- 
mation of emboli. 

Small port-wine stains may be removed 
by electrolysis or multiple incisions, but 
extensive stains are ineffaceable. Small 
nevi may be ligated under harelip pins; 
larger nevi may be strangulated in sec- 
tions by the Erichsen suture (Fig. 119), or 
may be completely excised. Excision is 
usually the best plan for the cure of angio- 
mata. It is rapid, thorough, and leaves 
but a trivial scar. Excision should always 
be employed if we feel sure that the edges 
of the wound can be subsequently approxi- 
mated and that there will not be a dangerous 
loss of blood. It is sometimes justifiable to excise an angioma even when 
approximation of the wound will obviously be impossible. In such a case 
the raw surface should be covered with Thiersch grafts. 

Most superficial nevi and many cavernous angiomata can be treated by 




-Method of applying Erichsen's 
ligature. 



Lymphangiomata 



315 



excision. The incisions must be beyond the dilated vessels. In large angio- 
mata involving the skin and also deeper parts, or involving a structure, like 
the lip, which it is undesirable to remove, electrolysis should be employed. 
The operation should be carried out with aseptic care, and, if the tumor is 
large, an anesthetic should be given. 

The positive pole produces a firm and hard clot. One or more needles 
connected with the positive pole are inserted into the tumor, the needles be- 
ing insulated to within about a quarter of an inch of their points. A fiat 
moist pad is placed upon the skin near the tumor and is attached to the nega- 
tive pole, and the pad is moved from time to time during the operation. 

From twenty-five to seventy-five milliamperes is the proper strength, and 
the current is passed for ten minutes. The current is increased for a moment 
before withdrawing the needles, otherwise they will stick to the tissue and 
cause bleeding when torn loose. After the withdrawal of the needles the 
nevus will be found to be hard, but 
the hardness will gradually disappear. 
It may be necessary to repeat the opera- 
tion a number of times at intervals of 
ten days.* 

Lymphangiomata are tumors 
composed of dilated lymph-vessels and 
are often, though not invariably, con- 
genital (Fig. 120). A lymphatic nevus 
is a colorless or faintly pink elevation; 
if it is punctured with a needle, lymph 
flows from the puncture. One or sev- 
eral nevi may be present in the same 
individual. The dilatation is due to 
blocking of the lymph-channels. Local 
lymphangioma of the tongue is mani- 
fested by a cluster of papillary projec- 
tions containing lymph. MacrogJossia 
is a congenital enlargement of the an- 
terior portion of the tongue, which en- 
largement grows more and more marked 

until finallv the tongue is forced far out of the mouth. This condition of tongue 
enlargement is due to lymphangioma of the mucous membrane. Lymph 
scrotum is due to a similar growth. A collection of these warty-looking dila- 
tations is called lymphangiectasis. Just as cavernous angiomata constitute 
a variety of blood-vessel tumors, so cavernous lymphangiomata constitute a 
variety of lymph-vessel tumors, and the spaces of the latter are filled with 
lymph instead of with blood. Areas affected with lymphangiectasis are liable 
to repeated attacks of erysipelas-like inflammation. Whether this inflam- 
mation is causative or secondary is not known. In tropical countries blocking 
of lymph-channels may be brought about by the filaria sanguinis hominis, a 
parasite which lurks in the lymph-vessels during the day and is found in the 
blood only at night. Lymphangiectasis is often the first stage of elephan- 
tiasis. 

* Cheyne and Burghard's "Manual of Surgical Treatment." 




Fig. 120. — Cavernous angioma, lymphan- 
gioma and lymphangiectasis, also beginning 
cancer. 



3i6 



Tumors or Morbid Growths 



Treatment. — A lymphatic nevus requires excision. In macroglossia the 
bulk of the mass should be removed by a V-shaped cut, the mucous mem- 
brane being sutured so as to cover the stump. In conditions due to the filaria, 
anilin-blue has been given internally. 

Malignant Connective=tissue Tumors, or Sarcomata. — The sarco- 
mata are composed of embryonic tissue-cells, the intercellular substance being 
very scanty and they resemble a process of chronic inflammation. They de- 
velop from connective tissue, rarely have a definite stroma, and the constituent 
cells, as a rule, proliferate with great rapidity. If a sarcoma has a stroma of 
connective tissue, this stroma contains lymphatics and such a sarcoma in- 
fects adjacent glands. In most cases there is no connective-tissue stroma and 
no lymphatics. In a sarcoma without a definite stroma the blood-vessels are 
not surrounded by lymph-spaces and are quickly invaded by cells (B. H. 
Buxton). The rapidly growing forms are very vascular, the blood flowing in 
vessels whose walls are very thin or running in canals lined by endothelium 
and bounded by sarcomatous cells. Such a tumor may pulsate and have a 
bruit, and hemorrhage often takes place into its substance. A rapidly-growing 
soft sarcoma with dusky skin above it (Fig. 122) maybe mistaken for an abscess. 
A slow-growing sarcoma has but few vessels. Sarcoma tends strongly to infil- 
trate adjacent parts. The growth disseminates by means of the blood and the 
vessel- walls, particles of the tumor being carried by the venous blood to the 

heart and from this organ to the 
lungs, where they lodge and form 
secondary growths. Emboli from 
these secondary foci are sent out by 
the arterial blood to various portions 
of the body, as the bones, kidneys, 
brain, liver, etc. This process is 
known as "metastasis." In some 
cases sarcoma is disseminated widely 
throughout the body, almost all the 
tissues showing minute white spots 
of secondary sarcoma which resem- 
ble tubercles. Such widespread dis- 
semination is called sarcomatosis. 
Sarcoma follows the vein-walls for 
considerable distances and builds 
elongated masses of tumor-substance 
inside the veins. The tumor may 
possess a capsule when it is in an early stage, but soon loses this except in very 
slow-growing varieties or in mixed forms growing by central proliferation, 
but secondary sarcomata are often encapsuled. Sarcomata may arise at any 
age from birth to extreme senility, but they are commonest during youth and 
early middle age. They are not hereditary, and often follow traumatism 
and inflammation. A number of observers maintain that they are due to 
parasites (the question of the parasitic origin of malignant disease is discussed 
on page 299). A sarcoma may be primary or may arise from malignant 
change in an innocent connective-tissue growth (chondrosarcoma, fibrosar- 
coma, etc.). A sarcoma rarely affects adjacent lymphatic glands unless it 




Fig. 121. — Sarcoma of the antrum. 



Malignant Connective- tissue Tumors, or Sarcomata 317 




Fig. 122. — Small round-celled fungating sarcoma of neck. 




Fig. 123 — Small round-celled sarcoma of neck. Skin has given way and a bleeding mass is exposed 



3i8 



Tumors or Morbid Growths 



contains lymphatics, and the great majority of sarcomata do not contain 
them. Occasionally sarcoma-cells are carried to adjacent glands by the 
vein-walls rather than by the lymph-stream. Sarcoma of the tonsil, sarcoma 
of the testicle, melanotic sarcoma, and lymphosarcoma do affect the glands. 
The skin over the tumor may give way, a bleeding fungus-mass protruding 
fungus haematodes) (Figs. 122, 123, and 124), and suppuration may cause septic 

enlargement of adjacent glands. 
After removal of a sarcoma the 
growth tends to recur, and the 
recurrent tumor may be either 
more or less malignant than its 
predecessor, the degree of malig- 
nancy being in direct ratio to the 
number and smallness of the cells. 
A sarcoma is malignant by local 
tissue-infection and by dissemina- 
tion. Sarcomata rarely cause 
pain when they are not ulcerated. 
They are commonest in the skin 
and connective tissue of the 
extremities, but they arise also 
from bone, neuroglia, periosteum, 
the lymphatic glands, the breast, 
the testicle, the eyeball, the paro- 
tid, and other parts. Not unusually 
Hemorrhages into a sarcoma often 




Fig. 124.— Sarcoma of neck (Horwitz). 



a pigmented mole becomes sarcomatous. 




Fig. 125. — Dr. \V. R. Bishop's case of small-celled sarcoma of the antrum- 



Malignant Connective-tissue Tumors, or Sarcomata 319 




Fig. 126. — Dr. W. R. Bishop's case of small-celled sarcoma of the antrum. 




Fig. 127. — Osteosarcoma of eighteen months' standing of right side of superior maxilla. Note bony 
lump on left side of lower jaw. 



320 



Tumors or Morbid Growths 



occur, with the result of suddenly increasing the size of the mass and forma- 
tion of blood-cysts. Sarcomata are subject to partial fatty degeneration, to 
myomatous changes which produce cavities filled with fluid, to calcification, 
and occasionally to necrosis of large masses. 

Varieties of Sarcomata. — The following species of sarcomata are recog- 
nized: 

i. Round-celled sarcoma is a tumor composed of round or spherical cells 
and resembling a chronic inflammatory area. The intercellular substance 
is scanty, the mass is soft and vascular, and grows with great rapidity. It 
often softens, and may become cystic. The cells may be small or large. The 
smaller the cells the more malignant the growth. A growth composed of 
small round cells is the most malignant form of sarcoma (Fig. 128). Lym- 
phosarcoma is a form of round-celled sarcoma which arises from lymphatic 
glands, lymphoid tissues, the thymus gland, the spleen, and some other 




Fig. 12S. — Small round-celled sarcoma of the neck. 



structures. The structure of a lymphosarcoma resembles the structure of 
a lymph-gland in the fact that it has a reticulum which looks like lymph- 
adenoid structure. Chloroma is a form of lymphosarcoma arising particularly 
from the periosteum of the bones of the cranium and face. The cells contain 
greenish pigment, hence the name. What is known as glioma of the eyeball 
is not a true glioma, but is really a sarcoma composed of small round cells. 
2. Spindle-celled sarcoma is a tumor composed of large or small spindle- 
shaped cells lying in a matrix, which may be homogeneous, but which may 
show some attempt at fiber-formation. Angular cells and stellate cells are 
often present. The cells may be placed in columns, which are at some places 
nearly parallel, and which at others diverge or interlace. Often there is no 
orderly arrangement. Spindle-celled sarcomata are usually harder than round- 
ceiled growths, but are sometimes quite soft. Cystic changes may occur. 
If there is a large amount of intercellular substance the growth is known 



Varieties of Sarcomata 



321 



as a fibrosarcoma. A rhabdomyoma is really a spindle-celled sarcoma con- 
taining striated muscle-cells. The spindle-celled sarcomata often contain 
cartilage. Spindk -celled growths are by no means as malignant as round- 
celled tumors. Often they do not show any tendency to metastasis. 
The greater the amount of in- 
tercellular substance, and the 
fewer the cells, the less the 
malignancy. Spindle - celled 
growths constitute the ma- 
jority of sarcomata met with 
in practice. 

3. Giant-ailed or myeloid 
sarcoma is characterized by 
the presence of very large 
cells, with many nuclei look- 
ing exactly like the myelo- 
plaquesof bone-marrow. The 
remainder of the growth is 
composed of spindle-cells, of 
round-cells, or of both spin- 
dle-cells and round-cells. 

Such a growth is maroon-colored on section. It arises most usually from 
bone, especially from the interior of a long bone, hence is often called osteosar- 
coma. It may, however, arise from other structures than bone. It is the 




Fig. 12Q. — Spindle-celled sarcoma of 
of finger. 



sheath of flexor tendon 





Fig. 130. — Melanotic sarcoma. 



least malignant form of sarcoma. 'Metastases rarely occur, and the growth 
often admits of complete extirpation and cure. Some surgeons do not class 
these growths with sarcomata. 



3 22 



Tumors or Morbid Growths 



4. Alveolar Sarcoma. — Alveolar sarcoma is a tumor containing both 
round-cells and spindle-cells, and characterized by the formation of acini, 
filled with round-cells of large size resembling epithelioid cells. The walls 
of the acini are formed of spindle-cells and fibrous tissue, and in these tra- 
beculi are the blood-vessels. The collection of the cells in the alveoli 
makes the structure resemble that of a cancer. Such growths are often pig- 
mented. Alveolar sarcomata arise particularly from moles of the skin, but 
may arise from lymphatic glands, serous membranes, the testicle, and other 
parts. Such growths are very malignant. 

5. Melanotic or Black Sarcoma (Fig. 130). — The color of such a tumor is due 
to pigment in the cells or matrix. These growths are usually composed of 




Fig. 131. — Dr. Hansell's case of cystic myxosarcoma of the orbit. 

round-cells, but may consist of spindle-cells, and they are sometimes alveolar. 
Melanotic sarcomata spring from parts which contain pigment (the skin and 
the choroid coat of the eye); they are apt to arise from pigmented moles; 
they are very malignant; they implicate related lymphatic glands, and during 
their existence the urine contains pigment. 

6. Hemorrhagic sarcoma is a sarcoma containing blood-cysts which result 
from parenchymatous hemorrhages. 

7. Angiosarcoma takes origin from the outer coat of a blood-vessel. The 
growth is often very vascular, and when the blood-vessels are notably dilated 
the tumor is called a telangiectatic sarcoma. The ordinary forms of angio- 



Treatment of Sarcomata 323 

sarcoma are only moderately malignant, but alveolar and melanotic forms 
occur which are highly malignant. Angiosarcoma may arise in the skin, in 
a serous membrane, and in a salivary gland. 

8. Cylindroma, or Plexiform Sarcoma. — In this variety the cells adjacent 
to vessels have undergone hyaline or myxomatous degeneration: the cells 
distant from vessels are unchanged. Section shows the normal cells appar- 
ently contained in spaces with hyaline walls. These degenerative changes 
occur most often in the angiosarcomata. Cylindromata arise from the brain, 
salivary glands, lachrymal glands, and rarely from the subcutaneous tissue. 
The growths are only moderately malignant.* 

9. Mixed tumors consist partly of mature and partly of embryonic tissue, 
the cellular elements exceeding the adult elements in amount. Among these 
mixed tumors are fibrosarcoma or the recurrent fibroid tumor, myxosarcoma 
(Fig. 131), chondrosarcoma, gliosarcoma, and osteosarcoma. 

10. Endotheliomata are tumors springing from endothelium, and the name 
is retained no matter what change the growth ultimately undergoes. Many 
writers include under the term endothelioma psammoma, myxosarcoma, 
angiosarcoma, and plexiform sarcoma. Others consider endothelioma a 
special and characteristic form of sarcoma. Some would not consider it with 
the sarcomata at all. The growth may take origin from the "endothe- 
lium of the blood-vessels and of the perivascular lymph-spaces, of the lymph- 
vessels, and of the great serous cavities (peritoneum, pleura, meninges)." f 
The characteristic cell is the endothelial cell, usually known as the epithe- 
lioid cell. The structure of these tumors is very variable and depends upon 
the origin. Some tumors "recalling the original vascular network" ("Amer- 
ican Text-Book of Pathology"), others being distinctly alveolar. Many 
pathologists consider a psammoma of the dura to be an endothelioma with a 
fibrous stroma. A psammoma contains calcareous particles. In appear- 
ance an endothelioma strongly resembles cancer, and such a growth is often 
spoken of as endothelial cancer. Such growths can arise in many different 
situations, but are particularly common in the peritoneum, pleural mem- 
brane, membranes of the brain, ovary, and testicle. I have removed an 
endothelioma of the tonsil, and also one of the mammary gland. The pro- 
liferating endothelial cells lie in lymph-spaces. Many endotheliomata grow 
rapidly, secondary growths form, and metastases are apt to pass to the serous 
membranes. Certain endotheliomata grow slowly, do not infiltrate adjacent 
structure, and do not produce secondary growths. In the brain and cord endo- 
thelioma may produce no symptoms for a long time. It is not as yet possible, 
clinically, to distinctly recognize endotheliomata from ordinary sarcomata. 

n. Mycosis jungo'ides is a disease which resembles sarcoma in many 
particulars and may perhaps be a form of sarcoma. It attacks the skin and 
subcutaneous tissues. The skin at first becomes red and swollen; numerous 
nodules form; the nodules become distinct tumors, soften at their centers, 
and fungation occurs. Microscopically the tumor resembles a lymphad- 
enoma. Mycosis fungoides is considered by some pathologists to be multiple 
cutaneous sarcoma. 

Treatment of Sarcomata. — Remove a sarcoma at once if it is in an 

* Stengel, "Text-Book of Pathology." 

f "An American Text-Book of Pathology," edited by Hektoen and Riesman. 



3 2 4 



Tumors or Morbid Growths 



accessible spot. Never delay removal. Cut well clear of it. If affecting a 
part where amputation is impossible, the rapidly growing sarcomata will 
almost inevitably return, and the very malignant variety, if uninterfered with, 
may terminate life in six months; but even in such case operation postpones 
the evil day and renders it possible that death will occur from metastatic 
growth in an organ, and that the patient will escape the horrors of ulceration 
and hemorrhage from the original tumor. Slowly growing and hard tumors 
offer some prospects of cure. The mixed tumor (as a recurrent fibroid) may 
repeatedly recur, and yet the patient may be cured at last by a sixth, an 




Fig. 132. — Central sarcoma of the fibula. 



eighth, or a tenth operation. In a case of spindle-celled sarcoma of the breast 
the younger Gross performed 22 operations in the course of four years, and 
eleven years later the woman was well. In one case of recurrent fibroid of 
the neck, the younger Gross operated five times. Three years after his death 
I operated once, and two years later again. Nine years after the last operation 
she was alive and well. In sarcoma of a long bone amputation should, as a 
rule, be performed, though in some cases of giant- celled sarcoma of the radius, 
ulna, or fibula excision may be employed. Bloodgood has reported excellent 
results from excision in these cases. In sarcoma of either jaw-bone, excision; 
of the eye, enucleation; and of the testicle, castration, is demanded. Sarcoma 



Treatment of Sarcomata 325 

of the ovary in adults demands removal, but in children the operation is 
generally useless. Sarcoma of the kidney in adults calls for nephrectomy, 
but in children the operation is usually of little avail. In my experience, in the 
cases of sarcoma of the kidney which survived operation, the growth always 
appeared in the other kidney. In melanotic sarcoma remove the growth and 
adjacent lymph-glands, or in some cases amputate. Removal of a sarcoma 
when there is no hope of a cure is often justifiable to prolong life, to relieve the 
patient of a foul, offensive, bleeding mass, and to permit of an easier road to 
death by means of metastasis to an internal organ. In an inoperable case the 
ligation of the vessel of supply may do good. In sarcoma of the tonsil Daw- 
barn advises the extirpation of the external carotid artery and the ligation of its 
branches. The operation is performed first on the side of the tumor and in a 
week or so on the other side. I employed it in 5 cases with distinct but tem- 
porary benefit. Occasionally, though very rarely, suppuration cures a sar- 
coma Wyeth, of New York, reported a case of sarcoma of the abdominal 
wall. It was found possible to remove only part of the growth; suppuration 
followed and the tumor disappeared, and ten years later had not returned. A 
study of statistics seems to indicate that more cases of sarcoma are cured after 
operation if the wound suppurates than if it remains aseptic, and it has been 
proposed to deliberately infect the wound with pus germs to lessen the danger 
of recurrence. This proceeding, however, is dangerous to life. 

It has been observed that an attack of erysipelas occasionally greatly 
benefits a sarcoma, causing large masses of the growth to soften or to slough 
and exposing a granulating surface. Busch noticed this in 1866, but the fact 
had been observed in the seventeenth century. Interest was decidedly 
awakened by Billroth's case of sarcoma of the pharynx which was cured by 
an attack of facial erysipelas. It was suggested that in inoperable cases of 
sarcoma erysipelas might be established artificially. Fehleisen inoculated 
tumors with cultures of erysipelas. Lassar, in 189 1, employed the toxins 
(cultures rendered sterile by heat and filtration). In 1892 Coley began his 
observations. The first plan was as follows : a bouillon culture was made of 
the streptococci; this culture was filtered through porcelain and an injection 
was given once a day into and about the sarcoma. The first dose was nix, 
and it was progressively increased. The effort was to cause a febrile reaction, 
and sometimes the injections lead to softening or suppuration. Coley's 
present method is as follows: make cultures of erysipelas cocci in cacao broth; 
after three weeks inoculate them with the bacillus prodigiosus, and cultivate 
the mixed growth for four weeks. The mixed cultures are maintained at a 
temperature of 136 F. until they become sterile. This sterile fluid contains the 
toxins. The dose is from 1 to 8 minims. If the fluid is injected remote from 
the tumor the initial dose should be 1 minim. If the fluid is injected into 
the tumor the initial dose is j to \ a minim (YVm. B. Coley, in "Am. Jour. Med. 
Sciences," March, 1906). The dose should be gradually increased until a 
chill occurs in from one-half an hour to two hours after the injection, followed by 
a temperature of ioi°-io4° F. In some cases there is so much depression after 
reaction that injections are given every other day, but if safely possible, they 
should be given every day (Coley). The object is to obtain a reaction with 
each injection. The more vascular the tumor the more severe the reaction 
(Coley). If an area softens during treatment Coley advises us to open and 



326 



Tumors or Morbid Growths 



drain the softened area. If improvement is going to occur it usually begins 
in from one to four weeks. If there is no improvement within four weeks 
there will not probably be any. It seems definitely proved that cases are 
occasionally cured by Coley's fluid. Spindle-celled sarcomata are influ- 
enced most favorably. Round-celled sarcomata are very refractory and so 
are cancers. The method is not entirely free from danger. It seems of 
value in post-operative cases to prevent recurrence. For this purpose it is 
applied twice a week for several months. Emmerich and Scholl claim good 
results from the injection of erysipelas serum. A sheep is injected with cul- 




Fig. 133. — Keen's case of papilloma with angioma. 

tures of erysipelas, the blood is drawn, the serum separated, filtered to re- 
move cocci, and injected about the sarcoma. Results are not definite. 
Among other agents which have been used to inject inoperable sarcomata we 
may mention alcohol, chlorid of zinc, arsenic, corrosive sublimate, thiosina- 
min, pepsin, alkalies, etc. The injection of anilin products into the sar- 
coma, which has received a qualified commendation from some observers, 
has been abandoned by most surgeons. The x-rays are sometimes of 
benefit, but are not so serviceable as in carcinoma and possess a certain dan- 
ger, for occasionally, after using them, dissemination rapidly occurs. 

Adrenal Tumors. — Some of these tumors bear a strong resemblance 



Papillomata, or Warts 327 

to adenomata and carcinomata. Some adrenal 'tumors are benign and 
among such tumors we note fatty growth, fibrous growth, and a growth resem- 
bling glioma. Another benign growth imitates the structure of the cortex 
of the adrenal. Malignant tumors occur, and many of them are identical or 
almost identical with sarcoma. One form is composed of epithelioid cells 
and resembles endothelioma. 

Accessory adrenals are common. They are known as adrenal rests. 
"They are found oftenest in the connective tissue about the main adrenals, 
but also in the kidneys, the right lobe of the liver, along the renal vessels and 
spermatic veins, in the inguinal canals, and in the broad ligaments" ("Amer- 
ican Text-Book of Pathology"). Tumors may take origin from adrenal rests. 

Innocent Epithelial Tumors. — These growths imitate an epithe- 
lial tissue of the mature and healthy organism. 

Papillomata, or Warts (Fig. 133). — Papillomata are formed upon the 
type of cutaneous and mucous papillae. A papilloma consists of a fibrous 
stroma which contains blood-vessels and lymphatics and is covered with epithe- 
lium of the variety appertaining to the diseased part. Papillomata grow from 
the skin and from mucous membranes; they may be single or multiple; many 
may form in one region or various distant parts may be affected; they may be 
painless or may be ulcerated or bleeding; they vary in color from light pink 
to deep brown or black. Papillomata of the skin are usually hard; papillo- 
mata of mucous membranes are soft. A skin-wart may be smooth and 
rounded, or may look like a cauliflower, the epidermis upon it being very 
rough. A papilloma of a mucous membrane looks like a cauliflower. Papil- 
lomatous masses may gather around the anus, the vagina, or the penis during 
the existence of a filthy discharge {venereal warts) (Fig. 134), and crops of warts 
may appear on the hands of those who work in irritant material (as petroleum). 
Papillomata are apt to arise in mucous membranes about carcinomata or 
chronic ulcerations. A large crop of warts may disappear in a single night; 
hence the popular belief in the efficacy of charms. Warts are particularly 
common on the skin of the back of the hands and fingers, the skin of the back, 
and the skin of the neck and scalp. A single skin-wart may reach the size 
of a walnut and become pigmented. The squamous epithelium covering 
a skin-wart may become horny (a wart-horn). Other cutaneous horns arise 
from the nails, from the scars of burns, or from ruptured sebaceous cysts. • 

Villous papillomata grow chiefly from the bladder, but they may also grow 
from the stomach and intestine. A papilloma of mucous membrane covered 
with squamous epithelium looks like a wart of the skin. Papillomata of the 
larynx are formed of squamous epithelium. Villous papillomata form tufts 
like the villous processes of the chorion; they may be single or multiple, and 
may be sessile or pedunculated; they are very vascular, and are apt to bleed 
freely. Papillomata may arise in cysts of the paroophoron, in cysts of the 
mammary gland, from the choroid plexuses of the ventricles of the brain, 
and from the spinal membranes. Papillomata may give rise to hemorrhage 
or may impair the function of a part. Any papilloma may become a cancer. 

Treatment. — Venereal warts are treated by repeatedly washing with 
peroxid of hydrogen, drying with cotton, and dusting with a powder composed 
of borated talcum or of equal parts of calome